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EUOPEAN COURSE on SPINE RADIOLOGY CORONAL BALANCE ROME 23th January 2020
SCOLIOSIS CORONAL • Unequal length of the lower (AGEING SPINE) limbs Antoine Feydy • Coronal spinal deformity SERVICE DE RADIOLOGIE B – Scoliosis with vertebral HÔPITAL COCHIN - APHP rotation UNIVERSITÉ DE PARIS – Non rotational scoliosis
Case 1 Case 2 F59 – Back Pain F59 – Back Pain
• LUMBAR • LUMBAR CURVE DEGENERATIVE • ABNORMAL CHANGES SPINAL BALANCE • NORMAL SPINAL • ADULT BALANCE DEGENERATIVE SCOLIOSIS
Learning Objectives IMAGING ADULT DEGENERATIVE SCOLIOSIS Adult Degenerative Scoliosis
• ADS : coronal and/or sagittal • ADS definition deformity and axial rotation • ADS classification • Spinal curvature can be accentuated in case of • IMAGING tools osteoporotic VCF - Postural • ADS : equal gender distribution, - Stenoses with typical onset after 50 y of age and average age of 70.5 y - Bone - Muscles
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IMAGING Adult Degenerative Scoliosis ADULT DEGENERATIVE SCOLIOSIS • ADS typically affects the lumbar spine, with rotation limited to the apex of the deformity • ADS Diagnosis and Classification • Lateral listhesis (subluxation) of the vertebral bodies is FULL SPINE more common than with AIS • Spinal parameters FULL BODY • 55% of cases of ADS will have degenerative • Pelvic parameters XRAY spondylolisthesis, and up to 34% have rotatory listhesis • Reproducibility for follow-up EOS • Prognostic factors for curve progression include degree • STENOSIS of apical vertebral rotation, Cobb angle greater than • BONE CT 30°, lateral listhesis (subluxation) of at least 6 mm • NERVES MRI • MUSCLES
ADS – Global Spinal Balance Cobb Angle Coronal Tilt C7 PLUMB LINE • CORONAL balance • SAGITTAL balance • Spinal parameters • Pelvic parameters
• IMAGING FOLLOW-UP
Sagittal Tilt ADS : SRS-Schwab classification SVA of Thoracolumbar Scoliosis / Coronal Curve Types Pelvic Tilt
• Most commonly used classification for ADS • Based on a multicenter, prospective, and clinical series of spinal deformity in which radiographic parameters were correlated with clinical outcome measures
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ADS : SRS-Schwab classification F93 of Thoracolumbar Scoliosis / Sagittal Modifiers
SRS-Schwab L0/0/0/
F65 Adult Degenerative Scoliosis SRS-Schwab Stenosis - Symptoms Double Curve D++/+/0 • Spinal stenosis is frequent • Back pain is common, most often occurring on the convex side of the spinal curve, and is related to the radiographic degree of lateral listhesis (subluxation) and sagittal imbalance • Pain on the concave side of the spinal curve may be caused by radiculopathy, and is reported to occur in 47-78% of patients
IMAGING ADULT DEGENERATIVE SCOLIOSIS
• STENOSIS • BONE • DDD CT • SPINAL CORD MRI • NERVES • MUSCLES CT with oblique and curved MPR MRI Full Spine with CT with oblique and curved MPR Sag + Coro + Ax T2w
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F72 Back pain and right radicular pain ADS Cohort ADS with multilevel Erosive DDD 76 patients Ferrero et al. • 72% had lumbar curves and 28% had thoraco-lumbar curves
STENOSIS ANALYSIS - CT Central and Foraminal Stenoses
• Central • Lateral • Foraminal
Do Curve Characteristics influence Stenosis Location CENTRAL STENOSIS ANALYSIS in 76 PATIENTS and Occurrence of Radicular Pain in ADS? Ferrero et al. HEGP Paris-Descartes Ferrero et al. HEGP Paris-Descartes • Central lumbar spinal stenosis • 76 patients (69±9 years old, 77% female) was found on average over 2 • 60% had neurogenic claudication, L5 was the most common radicular pain (41%) levels • 78% had Rotatory Subluxation (most frequent level • Severe stenosis in 72% (n=55) L3L4). In 50% of the cohort, RS at junction between • All the 20 patients with L4L5 lumbar and lumbosacral curves degenerative spondylolisthesis • 70% had central stenosis at junction between lumbar and lumbosacral curve had a central stenosis • Foraminal and lateral stenosis most frequently observed in the concavity of the distal lumbo-sacral curve CENTRAL
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FORAMINAL STENOSIS ANALYSIS in 76 PATIENTS IMAGING Ferrero et al. HEGP Paris-Descartes ADULT DEGENERATIVE SCOLIOSIS • Foraminal stenosis in 58% • (n=44) and located at the STENOSIS junction between main lumbar • BONE and distal lumbosacral curve in • DDD CT 14 cases • SPINAL CORD MRI • Foraminal stenosis most • NERVES frequently in the concavity of • MUSCLES the lumbosacral curve (29%, n=22), followed by the FORAMINAL In Some Symptomatic Patients concavity of the main lumbar curve (22%, n=17) CT + MRI
F68 – Lumbar Rotatory Subluxation with severe lumbar degenerative changes M57 Foraminal stenoses - CT
M57 - Foraminal stenoses MRI F59 Normal Lumbar Foramens - Cervical OK
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F65 – ADS and Cervical degenerative changes SAGITTAL BALANCE: MUSCLES at MRI
• Erector muscles of the spine (Jun HS et al. Neurosurgery 2016) • Mercuri’s classification with MRI • Fat fraction of the paraspinal muscles
F68 – MRI Fatty Muscles ADS IMAGING Follow-up & Post Surgery • Evolution of Spinal parameters (SRS Schwab) • Cobb angle changes > 5° • Surgical planification
• Post Surgery • Postural analysis • Hardware and Bone
Full Spine MRI with Coronal and Axial T2w
F67 Follow-up 2015 - 2018 F46 – 2015 PRE-OP D/++/0/+ D/++/+/+ D/0/+/+
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F49 – 2018 POST-OP F70 ADS – POST-OP
Postural and Hardware Imaging Hardware failure
ADS IMAGING - CONCLUSION
• POSTURAL IMAGING with FULL SPINE • SAGITTAL and CORONAL SPINAL BALANCE
• CT and MRI • CENTRAL & FORAMINAL STENOSIS ANALYSIS • NERVE roots • MUSCLE
• REPRODUCIBLE IMAGING
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