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Espa Ingles A.Pdf Documento descargado de http://www.elsevier.es el 02/11/2012. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato. Radiología. 2011;53(2):116-133 ISSN: 0033-8338 RADIOLOGÍA Publicación Oficial de la Sociedad Española de Radiología Médica RADIOLOGÍA Incluida en Index Medicus/MEDLINE www.elsevier.es/rx Actividad acreditada en base a la encomienda de gestión concedida por los Ministerios de Educación, Cultura y Deporte y de Sanidad y Consumo al Con sejo General de Colegios Oficiales de Médicos con 1 crédito, equivalente a 4 horas lectivas. www.seram.es www.elsevier.es/rx UPDATE Computed tomography and magnetic resonance imaging for painful spinal column: contributions and controversies F. Ruiz Santiago,* M.M. Castellano García, L. Guzmán Álvarez, M. Tello Moreno Sección de Radiología Musculoesquelética, Servicio de Radiodiagnóstico, Hospital de Traumatología, Ciudad Sanitaria Virgen de las Nieves, Granada, Spain Received 7 May 2010; accepted 22 October 2010 KEYWORDS Abstract The use of tomographic imaging techniques, computed tomography (CT) and Spine; magnetic resonance imaging (MRI), to complement or replace plain-fi lm radiography in the Magnetic resonance study of spine pain is becoming more and more common. imaging; The aim of this paper is to provide a general review of the CT and MRI manifestations of the Column; wide spectrum of lesions that can cause pain in the spinal column. This spectrum includes Computed degenerative disease, malalignment, tumors, inflammatory processes, and infectious tomography; processes. Back pain; Precise knowledge and accurate reporting of the fi ndings at CT and MRI are fundamental for Spinal column clinical decision making in patients with spine pain. disease; © 2010 SERAM. Published by Elsevier España, S.L. All rights reserved. Curvature of the spine PALABRAS CLAVE Tomografía computarizada y resonancia magnética en las enfermedades dolorosas Columna; del raquis: aportaciones respectivas y controversias Resonancia magnética; Resumen Las técnicas de imagen tomográfi cas, tomografía computarizada (TC) y resonancia Raquis; magnética (RM) se vienen usando cada vez de forma más frecuente, en sustitución o adición a Tomografía la radiografía simple, para el estudio del dolor de espalda. computarizada; El objetivo de este trabajo es realizar una revisión general de las manifestaciones en TC y RM Dolor de espalda; del amplio espectro de enfermedades que pueden ser responsables del dolor generado en la Enfermedades columna vertebral. Este espectro abarca la enfermedad degenerativa, de la alineación vertebral, de la columna; tumoral, infl amatoria e infecciosa. Curvatura espinal El conocimiento y la descripción exacta y uniforme de los hallazgos con dichas técnicas suponen un soporte fundamental para la toma de decisiones clínicas en los pacientes con dolor de raquis. © 2010 SERAM. Publicado por Elsevier España, S.L. Todos los derechos reservados. * Corresponding author. E-mail: [email protected] (F. Ruiz Santiago). 0033-8338/$ - see front matter © 2010 SERAM. Published by Elsevier España, S.L. All rights reserved. Documento descargado de http://www.elsevier.es el 02/11/2012. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato. Computed tomography and magnetic resonance imaging for painful spinal column: contributions and controversies 117 Introduction perfusion, in-phase and opposed-phase sequences, etc. Their use is less common and usually reserved for tumor The expanding use of tomographic imaging techniques, imaging. 7 computed tomography (CT) and magnetic resonance imaging (MRI), has led to a relative decline in the use of plain chest radiography as the first imaging technique in multiple Clinical and radiological considerations conditions that manifest with back pain. 1 Clinical guides do not recommend systematic imaging in Spine CT and MRI studies in asymptomatic patients have patients with acute or chronic back pain in the absence of reported a high percentage of vertebral disc disease. On warning signs (red fl ags), since this does not signifi cantly the other hand, there are also symptomatic patients that improve the clinical outcome. 2 Only in the presence of show no pathological changes on imaging studies. 9 warnings signs (fever, weight loss, history of tumor or Many of these disorders are age-related and may be neurological disorders) imaging techniques assume a central asymptomatic or show a symptomatic period of variable role. duration that may sometimes become chronic. One of the Inter-reader variability in the interpretation of the great challenges of imaging techniques is to reliably fi ndings is one of the factors that lead to disagreement in differentiate between symptomatic and asymptomatic 3 the decision-making process. In the present work, we conditions. Modic changes, particularly type I, seem to be assess the diagnostic contributions, advantages and strongly associated with back pain, whereas weaker limitations of CT and MRI in the evaluation of painful spinal association is found with disc disorders. 10 As for facet conditions. joint osteoarthritis, some authors consider it rare in asymptomatic patients, 11 but others fail to find a statistically signifi cant association between this condition Technical considerations and back pain. 12 CT provides high spatial resolution for anatomical imaging and it is particularly indicated in the evaluation of bone Causes of back pain lesions. From imaging acquisition in the axial plane, multidetector computed tomography (MDCT) allows for The causes of back pain can be classifi ed into mechanical isotropic images with no significant spatial distortion in and non-mechanical. Mechanical pain is secondary to 4 multiplanar and 3D reconstructions. anomalous stress and tension on the spine and may be Spine CT imaging must include a continuous helical triggered or worsened by certain movements or physical scanning across the range of interest, which is determined activities. 13 It accounts for 97 % of the causes of vertebral by clinical criteria or by the presence of a lesion previously pain, including sprain, degenerative disc and facet joint identified by other imaging techniques. Submilimeter disease, spinal stenosis, spondylolisthesis and osteoporotic slices allow for isotropic images; however, for extensive fractures. Non-mechanical causes account for 1 %, studies, reconstruction thickness of 1-3mm may be including infl ammatory, infectious and tumor diseases. 14 acceptable. Pain secondary to trauma fractures, surgery and referred The major drawback of CT is radiation dose, much pain secondary to visceral lesions are excluded from this higher than that of conventional radiography, and it may study. range between 13-26 mSv depending on the instrumentation 5 and technical parameters. The use of low-dose CT with Sprain or soft tissue strain (fi g. 1) radiation levels of around 1 mSv is not universally spread. 6 Muscle strain and ligament sprain are the most common MR imaging offers better characterization of soft-tissue causes of acute lumbar and cervical pain in the general structures than CT. A standard protocol should include axial population. 14,15 and sagittal T1 and T2 sequences and, at least, one Muscle pain may appear without previous trauma or fat-suppressed T2-weighted sequence, based on techniques may be secondary to trauma strain or direct muscle of chemical shift and/or of inversion-recovery suppression. contusion. In muscles and ligaments, the severity of the Concerning the cervical spine and due to the smaller size of lesions ranges from overstretching to partial or complete the discs, the axial gradient echo sequence is recommended, rupture. which usually allows differentiation between disc Spine imaging is indicated only in cases of sprain secondary (hyperintense) and osteophytes (hypointense). 7 In case of to injury severe enough to make us suspect a spinal fracture, suspected infl ammatory, infectious or neoplastic disorders, in instability secondary to ligament rupture, or damage to the examination is completed with additonal T1 sequences nervous structures. obtained after gadolinium administration. Fat suppression MRI demonstrates edema of the paravertebral muscles in at least one plane allows better enhancement evaluation that may resolve or progress to atrophy of the involved of these pathological processes. 8 muscles. 16 In more severe cases, MRI shows ligament and Innovative MRI techniques are being developed that try capsular involvement or signs associated with instability, to provide metabolic, functional and physiological including interspinous widening, vertebral subluxation, information to the anatomical image of the standard vertebral compression fracture and loss of cervical methods. Some of these techniques are diffusion, lordosis. 17 Documento descargado de http://www.elsevier.es el 02/11/2012. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato. 118 F. Ruiz Santiago et al Figure 1 Lumbar sprain. Axial T1 W (A) and T2 W (B) images show edema in the paravertebral muscles (multifi dus muscle) (arrows) and atrophy in the area of the lumbar rotator muscles (*). C) Sagittal T2 image show yellow ligament rupture and disc herniation (arrows) following hyperfl exion injury. D) Cervical sprain. Sagittal STIR image demonstrates interspinous edema (arrow) in a patient with severe osteochondrosis and subchondral bone edema C5-C6 (*). Facet joint disease (fi g. 2) Degenerative disc disease
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