Adolescent Spondylolysis and Spondylolisthesis

Steven J. Gould, D.C., D.A.C.B.R. Central Plains Radiologic Services Cheney, KS.

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K. Bee. Competative Tennis/Running

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1 Purpose Purpose

  Review a common but commonly Up date of information on this condition; unidentified/ overlooked cause of back ◼ Classification (including a new classification scheme) M.Herman and P. Pizzutillo; Clinical Ortho. And Related Research. No. 434; pp. pain in adolescent athletes 46-54.  Treating chiropractors must be able to ◼ Incidence/ Etiology recognize the presence of this disorder, as ◼ Diagnosis (clinical and imaging) spinal manipulative therapy may be contra- ◼ Treatment options indicated.

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Classification (Wiltse)

Clinical Orthopedics and Related Research No. 117, June 1976

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Classification Spondylolisthesis (Wiltse)

 Type III: Degenerative; long standing  Spondylolisthesis Classification (Wiltse 1976) intersegmental instability  Type I: Dysplastic; Genetic variety of dysplasia of the neural arch  Type IV: Traumatic; acute traumatic fracture of the neural arch, other than the pars  Type II: Isthmic;  Type V: Pathologic; generalized or local bone ◼ IIA; lytic (spondylolysis) fatigue (stress) fx of pars, disease ◼ IIB; elongation of pars without separation ◼ IIC; acute pars fx; significant trauma

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2 Classification Classification

 Marchetti-Bartolozzi System  Marchetti-Bartolozzi System cont’d… ◼ Developmental ◼ Acquired

 High grade dysplastic  Traumatic ◼ With lysis ◼ Acute Fx ◼ With elongation ◼ Stress Fx  Low grade dysplastic  Post-surgery ◼ With lysis ◼ Direct surgery ◼ With elongation ◼ Indirect surgery

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Classification

 Marchetti-Bartolozzi System cont’d… ◼ Pathologic

 Local pathology  Systemic pathology ◼ Degenerative  Primary  Secondary

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NEW CLASSIFICATION SYSTEM New Classification System  Type I - Dysplastic  Type II – Developmental  Type III – Traumatic ◼ Type III A; Acute ◼ Type III B; Chronic

 Stress Reaction

 Stress Fracture

 Spondylolytic defect (nonunion of pars)  Type IV - Pathologic

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3 Wiltse compared / Herman(new) Spondylolisthesis / Spondylolysis  Wiltse ◼ Type II: Isthmic;  Prevalence of spondylolysis varies depending on type and  IIA; lytic (spondylolysis) fatigue (stress) fx of pars, population affected.  IIB; elongation of pars without separation  IIC; acute pars fx; significant trauma  1951 study of 4200 cadaver spines showed 4.2%  Herman (new) prevalence ◼ White men(2.8%), Black men (2.8%), White women  Type II – Developmental (2.3%), Black women (1.1%), Roche  Type III – Traumatic  4.4% found in 1st grade children in New York. As the ◼ Type III A; Acute cohort group reached adulthood, incidence raised to 6%. ◼ Type III B; Chronic Study also showed that spondylolysis is not present at  Stress Reaction birth, Fredrickson  Stress Fracture  Spondylolytic defect (nonunion of pars)

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Athletic populations

 As high at 47% of young athletes present to sports injury  Ferguson, studied back pain in college clinic with LBP, Micheli football linemen, found 24% had

 Rossi, retrospectively reviewed radiographs of elite spondylolysis and 8% incidence of athletes in Rome and found 16% prevalence of spondylolisthesis. spondylolysis in athletes in general with higher rates for specific sports. ◼ Divers (83%), Weight Lifters (45%), Wrestlers (33%), Gymnasts (38%), high jumpers (24%). Prevalence of spondylolisthesis is these patients was 32%.

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Athletic populations

 Soler and Calderon; found spondylolysis in 8% of Spanish athletes ◼ (Throwing sports were highest at 27%, followed by artistic gymnastics (17%), and weightlifting (13%). ◼ Found higher incidence in women.

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4 https://www.ncbi.nlm.nih.gov/pubmed/27040065

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Athletic populations

 Jackson, studied gymnasts  found 11% spondylolysis in asymptomatic women ◼ 54% of whom had spondylolisthesis.

Free article link: https://www.jstage.jst.go.jp/article/jmi/63/1.2/63_119/_pdf

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5 ◼ Lumbar spine MRI in the elite-level female gymnast with low back pain. Bennet DL, Nassar L, Delano MC Skeletal Radiol. 2006 Jul;35(7):503-9. Epub 2006 Mar Athletic Populations

◼ Hypothesis is that MRI will demonstrate the same type of abnormalities in both the symptomatic and asymptomatic gymnasts.  Elliott reviewed studies of Fast bowlers and found prevalence of spondylolysis to be up to ◼ Studied 19 Olympic Level Gymnasts ages 12-20. 55%. ◼ RESULTS: Anterior ring apophyseal injuries (9/19) and degenerative disk disease (12/19) were common. Spondylolysis (3/19) and spondylolisthesis (3/19) were found. Focal bone-marrow edema was found in both L3 pedicles in one gymnast. ◼ History and physical exam revealed four gymnasts with current low back pain at the time of imaging. There were findings confined to those athletes with current low back pain: spondylolisthesis, spondylolysis, bilateral pedicle bone-marrow edema, and muscle strain.

◼ CONCLUSIONS: Our initial hypothesis was not confirmed, in that there were findings that were confined to the symptomatic group of elite-level female gymnasts.

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Fast Bowlers OR Holy Rollers

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Fast Bowlers

 Stretch,Botha, Chandler, and Pretorius (South African Med. Journ.) Aug 2003, Vol. 93. No. 8  Studied 10 cricketers, with lower back pain. Dx via x-ray, SPECT, and CT scan.  2nd and 3rd CT scans done at 3 months and 12 months after initial.  Radiographs normal in 8 subjects, 2 had evidence of sclerosis.  SPECT showed uptake in all subjects. CT showed No Fx in 3, Partial Fx in 3, complete Fx in 2 and old Fx bilaterally in 2.

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6 Fast bowlers; FAST BOWLERS

 Tx; conservative via physiotherapy modalities, postural correction and specific individually graded flexibility, stabilization, strengthening and cardiovascular programs  Complete healing was achieved in all subjects at 12 months,  a. SPECT c. partial fx, exception of 1 that showed near-complete union, with a small area of fibrous union at inferior border.  2 old bilateral fractures remained un-united.

 b. no fx on CT d. union w/ sclerosis 12 mnth followup

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Fast Bowlers Cont’d… Etiology

 Repetitive Stress injury of the pars interarticularis. A. sag. Partial fx c. significant healing at 3 mnth  Extension/Hyperextension and Extension with Rotation.

b. fx before partial d. x-ray at initial ct healing show no fx

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7 Etiology Etiology

 Familial tendency noted. (Native  Weakness from dysplastic elements. Alaskans/Eskimos; Frequency approaches 60% in ◼ Spina bifida occulta related to relatives of affected individual.) spondylolysis ~ 22- 92%. McTimoney and  Wynne-Davies and Scott; 19% in first-degree Micheli. relatives. Isthmic lesions (33%) more commonly ◼ Spina Bifida occulta without spondylolysis associated compared to dysplastic types. is about 7%.  Fredrickson; similar results and noted spondylolysis ◼ Gracile, thin pars in dysplastic cases. not present at birth.

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Spondylolysis Stress Fx Risk Factors for Spondylolysis Clinical presentation  Heredity  Signs and symptoms;  Male sex ◼ Adolescent age range, commonly preadolescent  Type of sport growth spurt. ◼ Asymptomatic or Symptomatic, May be ◼ Presence of spina bifida occulta is associated discounted as “growing pains”  Pain in low back that occasionally radiates to the iliac region, buttocks, or posterior thigh. ◼ Repetitive hyperextension and rotational activities.

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Spondylolysis Stress Fx Spondylolysis Stress Fx Clinical presentation Clinical presentation

◼ Pain with running and/or jumping ◼ Positive extension test of lumbar spine ◼ Pain relieved some with rest ◼ Positive “Stork Test”. Single leg standing ◼ Pain may be of several months duration with spinal extension (validity in ?) that changes intensity with activity changes. ◼ Positive “Jump or Hop Test”. Hop in place and land on flat feet or on heels with legs ◼ May have single episode that brings patient straight to jolt the spine. for care. (over the threshold from annoyance to more severe pain).

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8 Spondylolysis Stress Fx The use of the one-legged hyperextension test and Clinical presentation magnetic resonance imaging in the diagnosis of active spondylolysis Lorenzo Masci 1*, John Pike 2, Frank Malara 2, et.al. Q: Differentiate stress reaction/fx vs. facet syndrome or Br J Sports Med. Published Online First: 15 September 2006. mechanical back pain? doi:10.1136/bjsm.2006.030023

 Conclusions: These results suggest that there is a high rate of active spondylolysis in active athletes with low A: back pain. The one-legged hyperextension test is not ◼ Imaging; Changes in posterior arch useful in detecting active spondylolysis and should not be ◼ +/- radiographs relied on to exclude the diagnosis.  Also concluded that MRI less sensitive compared to ◼ edema on MRI, but +/- for pars lysis SPECT w/ CT ◼ increased activity on SPECT ◼ sclerosis or lysis on CT

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Magnetic Resonance Imaging in Diagnosis and Juvenile Spondylolysis: a comparative analysis of Follow-up of impending spondylolysis in CT, SPECT and MRI. Cambell RS, Grainger children and adolescents: Early treatment AJ, Hide IG, et al. Skeletal Radiol. 2005, may prevent pars defects. Cohen E., Stuecker RD. Feb;34(2):63-73. Epub 2004 Nov. 25. ◼ J. Pediatr.Ortho B. 2005 Mar; 14(2):63-7.

 Conclusion: MRI can be used as an effective and ◼ 14 pts (mean 12.4 yoa) unspecific activity related back pain >3 reliable first-line image modality for dx of wks with normal x-rays. juvenile spondylolysis. However, localized CT is ◼ Impending spondylolysis dx by typical signal abnormalities were recommended as a supplementary exam in confined to the pars interarticularis without fragmentation. selected cases as a baseline for assessment of ◼ Brace for 3 months: MRI signal returned to normal in 6 pts. healing and evaluation of indeterminate cases. And signal changes returned to normal in 1 patient at 6 months. MRI showed promising results in detecting and monitoring the early onset of spondylolysis.

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Case: Nic H Nic H; 16 yoa athlete

 16 yoa male with recent onset of LBP following running hurdles in track.  Previous episode of LBP with right iliac crest tenderness during football season (5 mnths earlier), resolved with three chiropractic care visits.  X-rays were obtained due to recurrence of LBP, positive jumping test, positive/ provocative lumbar extension.

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9 Nic H; 16 yoa athlete Nic H; 16 yoa athlete

 LAO and RAO plain film radiographic images  L5 pars irregularity

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Nic H; 16 yoa athlete Nic H;16 year old athlete  Sequential T2 sagittal images

 T1 , T2, and STIR para sagittal images ◼ Low signal L4 and L5 pars on T1 ◼ High signal L4 and L5 pars on T1 ◼ Slight increased signal L4 pars on STIR

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Nic H;16 yoa athlete Nic H; 16 yoa athlete  Sequential T2 Axial images L5/S1 – L4/L5.

 T1 Axial MRI; spondylolysis

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10 Nic H; 16 yoa athlete Nic H; PA and AP Bone Scan Images  Negative for pars uptake

 Axial T2 MRI; L5 spondylolysis  Increased T2 signal at pedicles, low on T1, consistent with edema

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Nic H; RPO and LPO Nic H. State qualifier for hurdles in high school track. Tx recommendations for rest, not taken well. Rested about 1.5 wks and returned to running, finished season, summer off. Walk on football play two years later at Washburn University, Topeka Ks.

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Dr Stovak patient Dr. Stovak patient  T1 and T2 sagittal MRI images

 Athlete referred to sports medicine specialist from family practitioner with LBP and pain on extension

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11 High Signal on STIR = pain Abstract •Lumbar spondylolysis is a prevalent sports-related disorder and a common cause of low back pain.

•5 athletes (4 males, 1 female) with severe low back pain.

•Mean age was 14.5 years.

•All five patients were found to have bilateral pars fracture.

•In all cases, staging based on the findings from computed tomography scan of the right and left pars fracture was different.

Neurol Med Chir (Tokyo) 58, 91–95, 2018

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Abstract cont’d…

• On short tau inversion recovery magnetic resonance imaging (STIR-MRI) of the comparatively newer more recently injured side, high signal intensity changes were obvious and dominant at the intra- and extraosseous area, which would indicate tissue edema and/or bleeding.

• Furthermore, the imaging findings corresponded to the CT scan STIR-MRI side of the low back pain. Case 1: 17-year-old male basketball player. Axial view of CT and • In conclusion, STIR-MRI can effectively distinguish between STIR-MRI. Circle shows bone marrow edema, arrows show extraosseous painful pars fracture and painless pars fracture. edema and bleeding around right pars fracture. Neurol Med Chir (Tokyo) 58, 91–95, 2018 Neurol Med Chir (Tokyo) 58, 91–95, 2018 69 70

Dr. Stovak Patient

 MRI reported as “normal study”  Spect images  MRI low T1 and High T2 at left pedicle and pars interarticularis, L5. CT scan STIR-MRI Case 2: 9-year-old male baseball player. Axial view of CT and  Spect images hot at left pedicle, L5. STIR-MRI. Circle shows bone marrow edema, arrows show extraosseous edema and bleeding around right pars fracture.

Neurol Med Chir (Tokyo) 58, 91–95, 2018 71 72

12 SPECT study performed at Dr. Stovak/Lieu Patient #2 Wesley Hospital;  T1 T2 IR  Left L5

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Dr. Stovak/Lieu Patient #2 Dr. Stovak/Lieu Patient #2  Axial images above and below L5 pars  T1 T2 IR ◼ Order Axial slices as “stacked” or contiguous ◼ Right side to ensure inclusion the pedicle and pars regions.

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Dr. Stovak/Lieu Patient #2 Dr. Stovak/Lieu Patient #2

 SPECT Exam

 Bone scan - - 2 dimensional ◼ SPECT is more sensitive due to removal of overlying antomy.

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13 Dr. Stovak/Lieu Patient #2 Dr. Stovak/Lieu Patient #2

 Bone window CT  Questionable defect at left pars of L5 ◼ L5 left pars defect

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Dr. Stovak/Lieu Patient #2 Plain film radiography

 Questionable defect at left pars of L5  AP and Lateral projections are minimum study.  Optional projections include oblique projections and tilt up lumbosacral spot projection will yield higher sensitivity to find pars defects.  Approx. 20% of pars defects noted on plain film are seen on oblique projections only. (Standert, Herring, Evidence Based Sports Med, 2003)  “absence of this finding (break in Scotty Dog neck) cannot rule out spondylolysis as it (lumbar oblique projection) detects the pars lesion in only 32% of cases (Saifuddin, White, Tucker, Taylor: Orientation of lumbar pars defects. JBJS. 1998.

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Pathogenesis of sports-related spondylolisthesis in adolesceents: Pathogenesis of sports-related radiographic and MRI study. spondylolisthesis in adolesceents: radiographic and MRI study.  Ikata et al., Amer. Journ. Sport Med. 1996.  Why slippage advances? ◼ Factors may include; age, sex, initial degree of ◼ Wedging of L5 vert. Body and rounding of slippage, angle of slippage, rounded S-1, the sacrum progressed as the slippage lumbosacral spina bifida. developed. These changes did not occur in ◼ Slippage progress more frequently during non-slip patient group. Therefore, the adolescent growth spurt. deformities are secondary to slippage. ◼ Controversy as to importance of L5 wedging and sacral rounding.

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14 Radionuclide Bone Scan/SPECT MRI

 Early study by Saifudde and Burnett reported admittedly poor results with MRI.  Standard two dimensional radionuclide bone scan is ◼ Study used TR=500 msec, TE=20 msec, 5-mm slices with 1 mm inter- not adequate. With availability of Single Photon image gap. They assessed only T1 weighted spin echo sagittal images Emission Computed Tomography (SPECT), SPECT and were unable to visualize the pars in 26.5% of cases.  Thick slices and wide interspace intervals were identified as should be included with the nuclear scan. factors that could be modified to decrease the number of false  SPECT has higher sensitivity and specificity than positives. (reported in McTimoney and Micheli. Current Evaluation and standard bone scan, due to planar imaging that Management of Spondylolysis and Spondylolisthesis; Current Sports Med. Reports, 2003). separates overlying structures.

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MRI MRI protocol for Spondylolysis

 Udeshi and Reeves:  Standard protocol at some imaging centers includes only; ◼ Used 3-mm thick slices T1 axials with .3-mm interimage  T1 and T2 sagittal images gap. Achieved 98.2% accuracy in assessing the pars on  T2 axial images through the disc spaces T1 and 93% accuracy on T2 weighted images.

◼ 4% rate of abnormal findings for the pars in both the T1  Must include consecutive (stacked) axial T2 slices to and T2 data sets. visualize the pars interarticulares and the pedicles. Otherwise  They emphasized that the aim of the study was to spondylolysis is not shown on axial exam. assess adequacy of visualization of the pars by MRI,  Inversion Recovery sagittal images are useful for sensitive not sensitivity/specificity of MRI for DX of evaluation of marrow edema. spondylolysis.

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MRI Grading System MRI Grading System

 Stress Reactions of the Lumbar Pars Interarticularis.The Development of a New Classification system.  Hollenberg, Beattie, Meyers, Weinberg, Adams, SPINE. Vol. 27, No. 2. Pp. 181-186. 2002 ◼ Show PDF file of Spine article.

Spine, Vol. 27, No. 2, pp 181-186. 2002

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15 MRI Grading System MRI Grading System

 3-mm slices, 0.5-1.0 – mm inter-image gap  Grade –3 = Visible complete unilateral or bilateral  Pts, with sports related back pain. spondylolysis and associated T2 abnormal signal.  Working DX of spondylolysis.  Grade –4 = Cases of complete spondyolysis without  Grading system applied abnormal T2 signal. Representing old, ununited fractures of ◼ Grade – 0 = normal, no signal abnormalities the pars. ◼ Grade – 1 = T2 signal changes consistent with edema, but  Normal pars interarticulares above or below the abnormal no lysis. (with or without pedicle and/or facet signal level as an internal control. changes)  Study looked at 55 subjects with sports related back pain, 28 ◼ Grade – 2 = T2 signal abnormalities and thinning, fragmentation, irregularity of the pars visible on T1 and/ females and 27 males. Primarily gymnastics and baseball or T2 weighted images. activities.

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MRI predictive of healing MRI predictive of healing

 Japanese study: 32 pts with suspected sponylolysis. (27 male, 5 female), (10-  17 age range) Japanese study; cont’d…  CT and MRI done. ◼ Tx; activity modification and soft corset ◼ CT categorized into four stages ◼ All very early defects, 82% of early stage, and  Very early (Faint partial hairline fx, unclear) 25% of progressive defects demonstrated bony  Early (obvious defect)  Progressive (larger fx without sclerotic mar.) healing. None of the terminal defects healed.  Terminal (fragmentation, sclerosis, pseudoarth) ◼ “High signal in the pedicle was a predictor of ◼ “All eight very early defects and 17 early defects showed high signal in bony union” Takata et al. Significance of high signal intensity of the pedicle. Even unclear defects on CT, clearly indicated abnormal pedicle on T2-weighted MRI for early diagnosis of pediatric lumbar findings on MRI” spondylolysis, presented at the annual meeting of the International Society ◼ Half of 16 progressive defects and none of the terminal defects showed for the Study of the Lumbar Spine, Vancover, 2003. Yet unpublished( The high signal at the pedicle. back letter. Nov. 2003 vol 18, No. 11)

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MRI signal changes of the pedicle as an indicator for early diagnosis of spondylolysis in children and adolescents: a clinical and biomechanical study. Sairyo K, Katoh S, Takata Y., et al. Sairyo K, Katoh S, Takata Y., et al cont’d…

 16 pts tx conserv. 15 boys / 1 girl at least 3 months  37 ped. Pts with spondylolysis  Results:  68 defects examined, staged and recorded on CT  CT staging; 8 very early, 24 late-early, 16 progressive, and 20 terminal.  High Signal Changes (HSC) on MRI compared with  All very early and late early showed HSC on T2 MRI. CT stages.  50% of progressive showed HSC on MRI  Spine. 2006 Jan 15;31(2):206-11.  0 of terminal showed HSC on MRI  TX: 16 pts with 29 defects >> 19 had HSC and 15 showed bony healing (79%).  None of the 10 negative HSC defects showed healing.

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16 Current Standard of Care Imaging cont’d…

 Plain radiographs; evaluate for obvious defects in  Dr. Gould opinion; pars  MRI is becoming and will become the gold  SPECT bone scan; to evaluate for “active” standard for imaging the pars interarticularis spondylolysis stress fx/ stress response question.  lysis or stress reaction in nonfractured pars.  No radiation. Reliable follow-up exam.  Computed tomography; to evaluate status of pars. No fx, acute fx, fx with sclerosis, or fx without  Prediction of healing by pedicle signal sclerosis. changes.  MRI; for questionable exams. Evaluate disc changes, and signal changes in posterior elements.

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Spondylolisthesis Treatment (Wiltse) Treatment

These are different patients than the athlete with spondylolysis  3. Less than 50% in a symptomatic child;  1. Up to 25% slip in an asymptomatic child; non-operative therapy including physical observe with standing radiograph initially every 6 therapy brace, and activity modification, in mnth until age 15, then annually until end of addition to recommendations of #2. growth; no limitation of activity, but should avoid  More than 50% slip in a growing child with or occupations involving heavy labor without symptoms should be treated  2. Between 25%-50% slip in an asymptomatic surgically. (McTimoney, and Micheli, current sports med. Reports 2003. child: same as #1, avoid contact sports or sports with lumbar extension.

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Treatment of spondylolysis Treatment of spondylolysis

 Moeller, Rifat; Spondylolysis in Active Adolscents,  Primary goal of treatment is to achieve a stable, pain free union of the fracture. The physician and sportsmed. Dec. 2001  Bony union is preferred. However, some authors have  Pain; refrain from activities that provoke pain for 4-6 deemed acceptable, a stable, pain free fibrous union. weeks.  D’Heercourt, et al Spondylolysis; returning the athlete to  Activity modification; eliminate hyperextension. sports participation with brace tx.  Physical therapy; hamstring flexibility and deep  Tx 73 adolescent athletes with Boston overlap brace. abdominal muscles with coactivation of the  Returned to activity at 4-6 weeks. multifidus proximal to the defect.  80% good to excellent clinical outcome.

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17 “warm and form” brace used by Sport Treatment of spondylolysis Med. Fellows at KU med.  Bracing; If no progress from initial program or pain worsens, then bracing with thoracolumbosacral orthoses.  Immediate vs. delayed bracing controversial  Brace no more than 6 months.  If no union and still symptomatic; surgery may be option.

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University of Wisconsin: Treatment/ Gould’s thoughts

 Tx and return to play decisions are on a case-by-case basis.  Tx may depend on the stage of the pars lesion at diagnosis. Patients with only edema reaction on MRI or SPECT and no defect, then may respond to activity limitation better than those with a frank defect in the pars.  Those with no edema signal on MRI or uptake on SPECT are not likely to unite and bracing may not be warranted, unless at risk for spondylolisthesis (slippage) progression.

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18 Core Rehab: Bird Dogs Bird Dog

 Active paraspinal myo (multifidi) in quadrants (right upper and left lower) (shown), then alternate.  Bird dogs are less stressful than the prone- two arm “super-man”, because the “Bird- Dog” lessens the compressive forces to the spine. (MacGill).

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Core Rehab: Planks Core Rehab: Planks

 Beginner: Knees and forearms  More advanced: forearms and toes

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 Plank type exercises force the contracture of the “muscular girdle” of the abdomen without compressing the spine.  Side planks contract the internal oblique abdominal muscles to better advantage.  Transverse abdominous and rectus abdominous  Side Plank – internal muscles are contracted with the standard plank obl. position.  All the plank postures with work the deep spinal muscles.  Curl- up – Rectus Abd.

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19  Cat-camel - warm up exercise.

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Runner with LBP --54 yoa

T2 weighted images

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T1 and T2 weighted Axial images

T1 weighted, parasagittal images.

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20 T1 weighted Axial Images Runner with LBP – 54 yoa

 Edema signal with HSC in posterior elements  Modic type I marrow changes with facet arthrosis vs. Edema from stress fracture.  Edema in bone indicating stresses leading to fracture. Different stress mechanism vs. adolescent athlete.  There is evidence of pars rupture as a result of advancing facet arthrosis with degenerative spondylolisthesis.

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T2 weighted Axial images LBP male age 13  Increased T2 signal in Left L5 pars  Decreased T1 signal in Left L5 pars

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LBP male age 13 Pedicle / pars edema left at L5 Dr. Sauer Pt. G.B.,KS.

 T2 axial image

 L5 pedicle edema bilaterally (left shown)  Volleyball player: 14 year old female.

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21 B.B. Dr. Sauer Pt. G.B.,KS.

 Facet sclerotic changes in a 14 yr. Old?  L5 pedicle edema bilaterally (right shown)  Axial cuts only at disc levels.  No inversion recovery images.

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LBP Male age 13 54 yoa male  Large Anterior Inf. Schmorl’s Node at L1 and anterior superior nodes at L2 and L3  Mid sagittal T2 grade one spondylolisthesis L5 on S1  Parasagittal T1 and T2; spondylolysis  T12 hemangioma with Increased signal on T1 and T2.

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54 yoa male Bonus case: 8 yoa female

 No edema at pars on T2 image  Lower back pain. 8 -9 months duration.  Spondylolysis is long standing  Cannot run, constant pain,  Receiving monthly OMT –osteopathic manipulation for tx.  No imaging.

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22 8 yoa female

 Has been seen at Large hospital in KC. DX with  Exam: reduced and painful ROM lumbar Sjorgren's and "hypermobility syndrome" No spine in all movements. spinal x-rays or imaging. Mother says someone did hip and knee plain films.  + hop test.  Crying pain to palpation at L/S junction.  Pt. cannot run due to pain in back. Visible gait  Cannot perform fast walking without limping change with splinting or protecting of the back with gait. trying to run, gets to a faster walk and her has adductor muscles hypertonicity pulling knees  DTR’s +2/4, Myostrength- legs +5/5, No together. (almost like spastic gait). Mother says sensory losses. before pain started this kid was an athletic gymnast.

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T2 T1 IR

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 Dx: biopsy of L/S region was inconclusive  Langerhans cell histiocytosis is a disorder in which excess immune system cells called Langerhans cells build up in the  Bone scan showed uptake in patella. Biopsy body. Langerhans cells, which help regulate the immune of patella reveals. Langerhans Cell system, are normally found throughout the body, especially in the skin, lymph nodes, spleen, lungs, liver, and bone marrow. Histiocytosis. In Langerhans cell histiocytosis, excess immature Langerhans cells usually form tumors called granulomas. Many researchers now consider Langerhans cell histiocytosis to be a form of cancer, but this classification remains controversial.

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 In approximately 80 percent of affected individuals, one or  Langerhans cell histiocytosis is often diagnosed in childhood, more granulomas develop in the bones, causing pain and usually between ages 2 and 3, but can appear at any age. swelling. The granulomas, which usually occur in the skull or Most individuals with adult-onset Langerhans cell the long bones of the arms or legs, may cause the bone to histiocytosis are current or past smokers; in about two-thirds fracture. of adult-onset cases the disorder affects only the lungs.  Other signs and symptoms that may occur in Langerhans cell  The severity of Langerhans cell histiocytosis, and its signs histiocytosis, depending on which organs and tissues have and symptoms, vary widely among affected individuals. Langerhans cell deposits, include swollen lymph nodes, Certain presentations or forms of the disorder were formerly abdominal pain, yellowing of the skin and whites of the eyes considered to be separate diseases. (jaundice), delayed puberty, protruding eyes, dizziness, irritability, and seizures. About 1 in 50 affected individuals experience deterioration of neurological function (neurodegeneration). 143 144

24 Summary:

 Older names that were sometimes used for  Stress reaction/fracture of the pars and forms of Langerhans cell histiocytosis posterior elements is a common condition in include; adolescents.  Eosinophilic granuloma, Hand-Schüller-  Treatment with CMT is not indicated in the Christian disease, and Letterer-Siwe disease. “Active” phase when MRI shows edema. Chiropractors must keep this diagnosis in the forefront when working with adolscent patients with back pain.

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Summary: THE END

 Lumbar- adolescent spondylolysis/ stress reaction occurs in a fairly narrow age range of adolescence to young adulthood.  Children younger than the adolescent age may have another diagnosis as the cause of their back pain, including infections and neoplasia.  Appropriate examination and imaging are required for diagnosis and treatment or referral.

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Thank YOU!

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25 Case # 1

Chiropractic Radiology Cases

Steven J. Gould, D.C., D.A.C.B.R. 73 year old female. Chronic LBP recent onset of sharp Central Plains Radiologic Services, P.A. lower back pain with weightbearing falling colonoscopy procedure. Normal 126 N. Main / P.O. Box 190 colonscopy without complication. Cheney, KS. 67025 History of Chronic Leukemia.

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Case 1

3 4

5 6

1 7 8

Findings

◼ Cystic mass lesion at Vert. Level of L1 ◼ Inversion ◼ High signal T2 and Low signal T1 recovery (lt) ◼ Intra or Extradural ? ◼ T1 sag +C ◼ Marked degenerative changes of Lumbar (rt) spine

◼ Schmorl’s nodes associated.

◼ Retrolisthesis of L2 upon L3.(instability ?)

◼ Spondylolytic spondylolisthesis L5 on S1

9 10

Differentials

◼ rd Post contrast T1 sagittal MRI ◼ Gamut M – 110 (Reeder and Felson 3 edition)

◼ Smooth walled enhancement around ◼ Extradural Mss with Normal Adjacent the cyst, ventrally and epidural fat Bone above and below the mass. ◼ At level of disk only

◼ Disk bulge ◼ Mass effect on the spinal cord/conus medullaris anteriorly. ◼ Extrusion ◼ Protrusion

◼ Epidural scar

◼ Marginal osteophyte.

11 12

2 Differentials Diagnosis Gamut M – 110 (Reeder and Felson 3rd edition) continued…

◼ Not necessarily at level of disk ◼ ◼ Arachnoid cyst Spinal Extradural Arachnoid Cyst ◼ Conjoined root sleeve ◼ Epidural abscess ◼ Epidural hematoma ◼ Epidural lipomatosis ◼ Epidural metastases ◼ Extruded or sequestered disk ◼ Lipoma (spinal dysraphism) ◼ Lymphoma ◼ “Pseudomass” at dens due to C1-2 subluxation in RA, etc… ◼ Root sleeve diverticulum ◼ Root sleeve ectasia ◼ Synovial cyst from facet joint ◼ Tarlov (perineural cyst) 13 14

Treatment: ◼ T2 axial and sag. Post Surgical Resection surg.

◼ Sag. T1

◼ 1 day -post surg.

15 16

◼ Axial & Sag. T1 +C

◼ 1 day - post surg.

◼ Prior MRI exam: 11 2007 MRI study

◼ Cystic mass was not present

◼ Increase in signal at the L1/L2 disc space.

◼ Question of discitis.

◼ Resolving discitis (infection/inflammation), implicated in cause of arachnoid cyst?

17 18

3 ◼ Prior MRI from 2007.

◼ Increased T2 signal at L2/L3 disc level: ? Diskitis ◼ Spinal extradural cyst was not present….. Not congenital etiology ◼ Post contrast T1 and IR images 19 20

Spinal extradural arachnoid cysts

◼ Spinal Extradural Arachnoid Cysts: Clinical, Radiological, ◼ rare cause of spinal cord compression and Surgical Feature ◼ most commonly occur; ◼ James K. Liu, M.D.; Chad D. Cole, M.D.; Peter Kan, M.D.; Meic H. Schmidt, M.D. ◼ middle to lower thoracic spine (65%) ◼ Neurosurg Focus. 2007;22(2) ◼ lumbar and lumbosacral (13%)

◼ thoracolumbar (12%)

◼ sacral (7%)

◼ cervical regions (3%)

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Clinical features

◼ Cyst enlargement can result in symptomatic spinal

cord compression. ◼ Arachnoid cysts generally develop in adolescents;

◼ Extradural arachnoid cysts develop from ◼ Male 2:1 over females protrusions of arachnoid herniating through a ◼ Thoracic cysts usually occur in young adolescents small dural defect. ◼ Thoracolumbar and lumbar cysts usually appear in ◼ Cysts contain CSF and communicate with adults in the 4th decade of life. subarachnoid space via a “pedicle” May be a ◼ Cysts often arise dorsally and can partially protrude check-valve (ball-valve) system with intermittent into the adjacent neural foramen. changes in CSF pressure allowing expansion of the cyst. (Or cells lining the cyst may produce fluid.) ◼ A single cyst can extend over several spinal segments, or multiple cysts with separate dural ◼ Cause is not known. Some considerations include; defects and communicating pedicles can compose ◼ congenital origin (e.g., spinal dysraphism, marfan’s) one lesion ◼ acquired from trauma, infection, or inflammation.[4]

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4 Clinical features Pathologic features

◼ Cervical and Thoracic cysts : ◼ Spinal arachnoid cysts have been classified into three major ◼ Spastic tetraparesis and impaired sensory levels, categories: ◼ Horner syndrome may occur with cysts in the cervical spine ◼ Type I: Extradural cysts without spinal nerve root fibers. ◼ Subdivided

◼ Thoracic cysts tend to present with progressive spastic ◼ Type I A: extradural arachnoid cysts paraparesis, but back pain is generally uncommon. ◼ Type I B: sacral meningoceles

◼ Lumbar and lumbosacral cysts classically present with low-back ◼ Type II: Extradural cysts with spinal nerve root fibers pain, radiculopathy, and bowel and bladder dysfunction. ◼ Type III: Intradural cysts

◼ Overall, motor weakness is usually more predominant than sensory loss ◼ In some cases, an extradural cyst can demonstrate substantial intradural extension. ◼ Symptoms can be intermittent and exacerbated by Valsalva maneuvers or gravitational positional forces ◼ Nearly all Type I A cysts show communication with the subarachnoid space. But, there has been report of non- ◼ Remissions and fluctuation in symptoms have been reported in communicating cysts. approximately 30% of cases.

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◼ The exact origin and pathogenesis of Type IA ◼ Congenital origin is further supported by reports of a spinal extradural arachnoid cysts remains familial syndrome: unknown. ◼ multiple spinal arachnoid cysts ◼ lower-extremity lymphedema (Milroy disease) ◼ Congenital origin postulated: Congenital ◼ and distichiasis (double rows of eyelashes) diverticula of the dura or herniation of ◼ Genetic component linked by association in arachnoid through a congenital dural defect. various cases with congenital pigmented nevi, diastematomyelia, multiple sclerosis, Marfan ◼ “The dural sleeve of the nerve root or the syndrome, neural tube defects, spinal dysraphism, junction of the sleeve and thecal sac are and syringomyelia. the most common sites for these defects, ◼ “Loss of tissue elasticity and the decrease in although less commonly the dorsal midline tensile tissue strength associated with Marfan syndrome may be connected with dural ectasia of the thecal sac is involved.” in the development of these cysts.”

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◼ A. Milroy disease. This involves lower leg swelling, present from birth (1 in 6000 births) (figure 3). It is caused by mutations in a gene responsible for embryonic lymphangiogenesis Imaging (lymph vessel development). As a result, lymphatics fail to develop properly, particularly in the leg. ◼ MRI ◼ Demonstrates lesion and extent of lesion. ◼ B. Lymphoedema Distichiasis. This involves leg ◼ Aids differentiation from other mass lesions swelling (figure 4) and is caused by mutations in a lymphatic developmental gene called ◼ Osseous changes, when present from long standing pressure FOXC2. effects; (body scalloping and IVF enlargement) As a result, the valves of large lymphatics ◼ Epidural fat capping the superior and inferior margins of the become incompetent allowing lymph to flow lesion may be seen and aids confirmation of extradural backwards. This impairment in lymph flow is location. exacerbated in the upright position as the lymph also has to work against gravity. Surprisingly, this condition is associated with a – C.T. with Myelography can reveal filling of the lesion with double row of eyelashes (distichiasis) (figure contrast media and confirms the communication with the 5), presumably because the lymphatics and the subarachnoid space and diagnosis. MRI may not show a eyelashes have a common developmental origin. The double row of eyelashes is present communicating pedicle, due to the compression from mass from birth but the lymphoedema develops only effect. after puberty. The reason for this is unknown but hormonal changes may be a contributory – Immediate post myelogram C.T., followed by 3 hour and 8 factor. hour delayed studies are performed to evaluate filling of the ◼ http://trendyscience.blogspot.com/2007/08/how-lymphatic- system-works.html cyst with contrast.

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5 Treatment

◼ Symptomatic patients are treated surgically.

◼ Complete removal is preferred over drainage, due to recurrence if it is not removed.

– Asymptomatic patients are “treated” by observation.

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Case # 2

30 year old male with acute onset back pain and bilateral leg pain and weakness. Decreased reflexes. Positive SLR. Mild fever

◼ http://www.medscape.com/viewarticle/557903_6

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◼ T1 Fat. Sat w/ Con.

• STIR sag. and • Axial T1 Fat. Sat with Contrast

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6 ◼ Axial T2 Sag T1 ◼ T2 and STIR sag

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Findings

◼ Irregular region of increased T2 signal within the spinal cord. Possible cord enlargement but mild.

◼ Enhancement of lesion post contrast

◼ Extends over several segments and is ◼ T2, FLAIR, irregular in configuration. DIFFSION; Brain Images

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Differentials Diagnosis

◼ Signs and symptoms of cord compression ◼ Acute Transverse Myelitis ◼ Differential for space occupying lesions.

◼ Imaging Differential

◼ Region of increased T2 signal intensity within the spinal cord.

◼ Trauma – cord edema / hematoma

◼ Transverse myelopathy – gliosis/myelomalacia

◼ M.S.

◼ Transverse myelitis: Cause? Viral, trauma, idiopathic

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7 Transverse Myelitis Imaging Findings

• Murthy JM, Reddy JJ, Meena AK, Kaul S. Acute transverse myelitis : MR characteristics. Neurol India [serial online] 1999 [cited 2008 Sep ◼ Transverse myelitis is a neurological disorder caused by 21];47:290. inflammation across both sides of one level, or segment, of the spinal cord. ◼ certain MRI characteristics help in differentiating acute transverse ◼ Symptoms of transverse myelitis include; myelitis from spinal form of multiple sclerosis. These include: ◼ a loss of spinal cord function over several hours to several weeks. ◼ usually begins as a sudden onset of lower back pain, muscle ◼ 1) centrally located high intensity signal extending over 3 to 4 weakness, or abnormal sensations in the toes and feet can segments and occupying more than two thirds of the cord cross- rapidly progress to more severe symptoms, including paralysis, sectional area and urinary retention, and loss of bowel control. ◼ some patients recover from transverse myelitis with minor or no ◼ 2) peripheral contrast enhancement of high intensity signal. residual problems, others suffer permanent impairments that affect their ability to perform ADLs. Most patients will have only one episode of transverse myelitis; a small percentage may have

a recurrence. ◼ http://www.neurologyindia.com/text.asp?1999/47/4/290/1587 • http://www.ninds.nih.gov/disorders/transversemyelitis/detail_transversemyelitis.htm

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◼ High signal intensity was the feature in 12 patients and one patient showed mild swelling of the cord with no signal alteration.

◼ The lesion extended over 3 or more segments in all the patients.

◼ Coronal sections clearly showed asymmetrical nature of the lesion

◼ The high signal intensity on axial T2 weighted images was centrally located in all the patients and occupied more than two thirds of the cross sectional area of the cord in 8 patients.

◼ Central dot sign, a small dot, isointense with the cord was seen in 7 of the 8 patients who had a large area of central hyperintensity.

◼ Variable, mild to moderate cord expansion was observed in 6 patients.

◼ Contrast study in one patient showed peripheral enhancement of the lesion.

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20

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8 21

Colon used to replace esophagus ???

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22 Full spine study : Cervical, Thoracic, Lumbar, and pelvis

Next case:

Back pain. Presents to chiropractor for care.

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53 54

9 S.E.D.

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10 Chiro Rad Cases II

Neck pain

1 2

Findings

• Osseous density attached to the occiput • Corticated with internal trabecular patterns

3 4

Differentials Diagnosis

Osteoma Osteoma of the occiputal bone Osteochondroma Myositis ossificans Monostotic Fibrous Dysplasia

Additional clinical correlation for Gardner’s Syndrome: Intestinal Polyposis and bone and soft tissue tumors.

5 6

1 Osteoma of occipital bone Meher R, Gupta B, Singh I, Raj A. Osteoma of occipital bone. Indian J Surg 2004;66:365-7. Cases from the Web…

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Ivory Osteoma Of Temporal Bone MVC Meher R. Online J Health Allied

Scs.2005;4:2 25 yoa Female Seen at hospital – released Chiro. office limited • mobilitiy and pain Films obtained. • • Findings? –

9 10

MVC MVC

11 12

2 Patient with neck pain

Hypertrophic changes consistent with DISH Cyst wall calcification in anterior lower cervical soft tissues.

13 14

Cyst wall calcification in anterior lower Shoulder Pain cervical soft tissues.

Differentials:

15 16

Shoulder Pain Shoulder Pain

17 18

3 58 Yoa Female

Rolling – round 6 ft. banquet table Legs of table unfolded, tripped the employee and she fell. Fell on a stack of crates with the table landing on her. Worked next weeks with left hand in pocket. Seen by medical personnel 3 months post- injury. Initital chiropractor. Tx given………

19 20

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4 LBP 1

LBP Hx of previous lumbar surgery Findings?

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Elderly Female Painful Gait- Fell?

Subsequent Films Months Later

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29 30

5 31 32

Elderly Female: 2

• Fell and now has painful gait

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25 yoa. LBP; ? Density at Close up; Right Pubic fx L5/S1

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6 Spatulated TVP left L5 with Accessory Joint Case # 14

Lower back pain and sciatica

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39 40

41 42

7 • L5 level • Sacral level.

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Findings Differentials

Destructive spinal changes with soft Infection tissue mass at the lumbosacral Neoplasm junction. Extraspinal and intraspinal components with central canal Primary stenosis created at L5. Secondary Intermediate enchancement on post contrast images with inhomogenous Soft tissue condition invading bone? enhancement Bony condition invading soft tissue? Migration of soft tissue mass in cephalad direction “lifting the ALL”.

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Diagnosis Discussion

Tuberculosis- confirmed Tuberculous Spondylitis Spine involved in 25 – 50% of skeletal cases of T.B. Most common at T/L junction Most cases two or more vert. But may be one level. 80% of cases begins in Vert. Body Thanks to Dr. Norman Pay, Neuroradiologist, Wichita KS. for this M>F case.

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8 Discussion Discussion

Discovertebral lesions; Abscesses: Osteolytic destruction of vert body Psoas abscess margins Extension into intervening disc space Other rad. Features Vertebral collapse with production of Bony ankylosis kyphosis (Gibbus deformity). Ivory vert. Atlantoaxial instability Paraspinal extension Subligamentous extension beneath the – Skeletal imaging: atlas of the spine and extremities: Taylor and Resnick ALL and or PLL

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Case #15 axial T2

LBP and Sciatica

51 52

Axial T1 Findings

Signal and morphology alterations in the kidneys, noted on axial images. Multiple circular or lobulated areas of increased T2 and decreased T1 signal. General enlargement of the kidney transverse dimension Lobulated contour of outer kidney margin.

53 54

9 Differentials Diagnosis

rd Gamut M – 126 Reeder and Felson’s 3 ed. Polycystic Kidney Disease Renal Mass ----Bright on T2 Hemorrhage (post-traumatic) Hydronephrosis Mutilocular Cystic Nephroma Polycystic Kidney Disease Pyonephrosis Renal or perinephric abscess Simple Cyst Urinoma

55 56

Discussion Discussion

As many as half a million people in the United States and 4 Further history to 6 million world-wide are estimated to have PKD. Patient’s father and brother also have Autosomal dominant PKD; the most common form PKD symptoms usually appear between the ages of 30 and 40 back and side pain and headaches. Half of patients develop kidney failure, on average around age 54 23,000 were on dialysis or had a transplant for kidney failure in 2003, making it this country’s fourth leading cause of kidney failure.

www.niddk.nih.gov ; www.pkdcure.org

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Discussion

Case # 16

C.T. scan of kidneys with PKD Neck pain, Mid back pain, lower Clinical photo of back pain. pkd from asteriskann.blogspo t.com

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10 Thoracic spine Right sided middle mediastinal or x-rays were right hilar mass. initally taken. Anterior or posterior location in the CXR done as chest???? follow-up Is there a silhouette sign?

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63 64

C.T. scan

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11 Findings Differentials

Well defined soft tissue density at Anterior mediastinal masses the right margin of the anterior The 4 T’s mediastinum. Silhouttes with and anterior cardiac “Terrible” Lymphoma margin Teratoma Thymoma Thyroid (intrathoracic goiter, adenoma, carcinoma)

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Gamut F- 67 Reeder and Felson’s 3rd ed. Diagnosis

Anterior Mediastinal Lesion Common Thymoma Aneurysm Bone lesion Cardiac enlargement Fat Deposition Hematoma Hernia (morgani, hepatic) Innominate or brachiocephalic artery dilatation, buckling, or aneurysm Lymphoma Pericardial cyst Pericardial disease Teratoid disease Thymic lesion (benign or malignant) Thymus, normal (hyperplasia) Thyroid Mass (intrathoracic goiter, adenoma, carcinoma)

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Discussion Radiographically; thymomas are typically round or oval Thymomas well-marginated and may contain some Most common primary thymic tumor. peripheral calcification. Slow-growing lesions Association with myasthenia gravis: Usually behave in a benign fashion. 50% of patients with thymoma have myasthenia gravis A subgroup of these tumors have an aggressive nature and are called invasive thymomas. 15% of patients with myasthenia gravis have a Invasive thymomas typically invade locally and thymoma. spread along pleural and pericardial surfaces, Among patients with myasthenia gravis and a but they can exhibit extrathoracic metastasis. thymoma, 25% show remission of their most patients are over the age of 40. But myasthenic symptoms after thymectomy.

Thymoma can occur at any age. http://brighamrad.harvard.edu/Cases/bwh/hcache/162/full.html

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12 Post Post thymectomy thymectomy surgical CXR surgical CXR

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Thoracolumbar pain Left foraminal disc herniation

• Sagittal T2

75 76

Right shoulder pain

initial CXR

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13 Bronchogenic CA with spinal mets.

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45 year old female with LBP.

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12 year old Diagnosis? female with LBP • Renal stones • Medical doctor diagnosed density as “milk in stomach from breakfast cereal.”

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14 12 year old 12 year old female with LBP female with LBP C.T. Scan showed an Adrenal-renal mass. • Lateral Diagnosis not known at this time. projection shows density Hamartoma, Pheochromocytoma, and of overlie renal carcinoma may be considered. posterior – spinal region.

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65 Year old male with shoulder pain and decreased ROM

• AP right shoulder projection Internal rotation. • External Rotation • Decreased acromiohumeral interval • Coracoclavicular lig. Calcification • Calcific deposit in axillary recess

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Jones Fx

Jones Fracture; Within 1.5 cm of tuberosity Acute or chronic injury variations High rate of non- union and/or recurrence

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15 Apical density

• Subclavian catheter • Tracheal deviation from scarring (toward density)

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Volume loss Volume Loss

• Tracheal shift to side of loss • Post pneumonectomy • Fx rib ?

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Lateral Multiple tiny Thoracic granulomas • Histoplasmosis • Small densities ? • Less likely T.B.

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16 8/30/2019

Image Radiography of the Lumbar spine Is  Who/ what / when / where / why?? Everything  Who/ Why: patients presenting with “red flags” DR. STEVEN J. GOULD CHIROPRACTIC RADIOLOGIST 316-542-3400 [email protected]

1 2

Who/ Why Who / Why

Imaging of Uncomplicated mechanical back pain is generally Indications of a more complicated status include back not recommended. Indications of a more complicated status pain/radiculopathy in the following settings: continued… include back pain/radiculopathy in the following settings:  7. Intravenous drug use.  1. Trauma, cumulative trauma.  8. Prolonged use of corticosteroids, osteoporosis.  2. Unexplained weight loss, insidious onset.  9. Age >70 years.  3. Age >50 years, especially women, and males with osteoporosis or compression fracture.  10. Focal neurologic deficit(s) with progressive or  4. Unexplained fever, history of urinary or other infection. disabling symptoms, cauda equina syndrome.  5. Immunosuppression, diabetes mellitus.  11. Duration longer than 6 weeks.  6. History of cancer.  12. Prior surgery

3 4

Sacralization with accessory joints. Lumbar spine imaging: Radiography

 Why ? Diagnose conditions that are not palpable or not expected clinically.

 Spondylolisthesis

 Segmental Instability

 Block vertebra, hemivertebra, or other congenital deformity

 Facet Tropism

 Sacraliztion / Lumbarization

 Lumbosacral accessory joint  When?  What?

5 6

1 8/30/2019

 When?

 Manipulation contemplated as modality, Radiography

 Differential diagnosis would change treatment options,  Disability determinations The initial evaluation of the LBP patient may also require  Proactive for malpractice protection? * further imaging if other red flags such as suspicion of (* not a great reason for imaging, but sometimes seems to be the “standard”) cancer or infection are present [16-17]. Radiographs have a role in evaluation of alignment, instability, and  What? Region of symptoms or source of referral. scoliosis, and in postoperative evaluation of  Basic versus complete study

 Special views: oblique and/or spot projections instrumentation and fusion.

 Standing/ recumbent / motion studies.

 Imaging of asymptomatic sites could lead to malpractice suits, due to unnecessary exposure to radiation. ACR Appropriateness Criteria®

7 8

MRI MRI

 LBP complicated by the red flags listed above may justify early use of CT or MRI even if radiographs are negative  MRI is efficacious for detecting red flag diagnoses, particularly using the short tau inversion recovery (STIR)  The most common indication for the use of these and fat-saturated T2 fast spin-echo sequences as well as imaging procedures, however, is the clinical setting of for evaluating facet arthropathy and edema. LBP complicated by radiating pain (radiculopathy, sciatica), as well as in cauda equina syndrome (bilateral leg weakness, urinary retention, saddle anesthesia),  MRI with contrast is useful for suspected infection and neurogenic claudication, spinal stenosis, and/or risk neoplasia. In postoperative patients, enhanced MRI factors as above. allows distinction between disc and scar when tissue extends beyond the interspace.  MRI of the lumbar spine has become the initial imaging modality of choice in complicated LBP, *ACR Appropriateness Criteria® 9 10

MRI Vertebral Endplate Changes Modic System  Although disc abnormalities are common on MRI in Type 1 T1 T2 IR = Edema asymptomatic persons, acute back pain with radiculopathy suggests the presence of Type 2 T1 T2 IR = fibrovascular demonstrable nerve root compression on MRI. Type 3 T1 T2 IR = Sclerosis  MRI findings of Modic endplate change, especially T1 T2 IR type 1, anterolisthesis, or disc extrusion are more strongly associated with LBP than findings of disc degeneration without endplate change

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2 8/30/2019

Computed Tomography

Superior bone detail; Especially useful for posterior arch structures of the spine. Facets, lamina, pars interarticulares, pedicles.  Trauma, stress fracture (spondylolysis), pseudoarthrosis, scoliosis, stenosis, Post-surgical – bone graft integrity, surgical fusion, and instrumentation. Discitis

13 14

Myelography, Myelography/CT Discography, CT Discography

 Localizes source of back pain when indeterminate with other less invasive studies and in patients with multilevel Myelography was the mainstay of lumbar disease. disc diagnosis until MRI.

Requires Lumbar puncture.  Disc injection required. Can perform weightbearing and  Variable patient responses ( some subjective element) flexion/extension views.  Limited specificity  MRI Type 1 Modic changes have high positive predictive value in identification of a pain generator at discography

15 16

MVC MVC

 25 yoa Female  25 yoa Female  Seen at hospital  Seen at hospital – released – released  Chiro. office limited  Chiro. office limited • mobilitiy and pain • mobilitiy and pain  Films obtained.  Films obtained. • • • Findings? • Findings?

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3 8/30/2019

MVC MVC

19 20

Radionuclide Bone Scan Dr. Stovak/Lieu Patient

 Bone Scan’s role has changed with usage of MRI  Questionable defect at left pars of L5  Moderate sensitive for tumor, infection, or occult fractures. Not specific for the Diagnosis.

 Bone Scan remains important for skeletal surveys – metastatic disease

 Painful facet arthrosis and pseudoarthrosis after spinal fusion may be positive and correlate with painful level and guide therapy.

DX of Spondylolysis: Bone scan with computed tomography (single emission computed tomography SPECT) with C.T. if SPECT is + is more sensitive than MRI.

Gould thought: However, two procedures that Irradiate patients compared to MRI. Risk benefit ratio may favor MRI

21 22

Dr. Stovak/Lieu Patient Dr. Stovak/Lieu Patient

T1 T2 IR  Questionable defect at left pars of L5 Left - L5

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4 8/30/2019

Dr. Stovak/Lieu Patient Dr. Stovak/Lieu Patient

T1 T2 IR SPECT Exam Right side

25 26

Dr. Stovak/Lieu Patient Dr. Stovak/Lieu Patient

Bone window CT L5 left pars defect

 Bone scan - - 2 dimensional  SPECT is more sensitive due to removal of overlying antomy.

27 28

definitions LMP  Acute low back pain Lumbosacral pain of less than 6-weeks duration.

 Radiculopathy Dysfunction of a nerve root, usually caused by compression or irritation of the root.  Make sure patients complete the patient  Spinal stenosis Narrow bony canal that may cause radiculopathy, or cauda equina syndrome. intake forms.  Herniated disc Herniation of the disc material beyond the confines of the interspace.  Make sure that we read the patient intake

 Sciatica Pain radiating down the leg(s) below the knee along the distribution of the forms. sciatic nerve, usually due to mechanical pressure and/or inflammation of lumbosacral nerve root(s).  Obtain consent for x-rays.

 Cauda equina syndrome Compression of multiple nerve roots, often resulting in bilateral motor weakness (legs), urine retention, saddle anesthesia.

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5 8/30/2019

31 32

Report Writing In Radiology Standards Of Care In Radiology Imaging Report

 Standards of care are those action steps in practice that  Importance of report writing in radiology help maintain high quality care of patients. These action  accurate recording of findings for; steps are compared to ones professional peers.  medical-legal situations  In radiology the basic “Standards of Care” are;  comparison with previous or future examinations  1. clinical need for radiographs/imaging  permanent record in the event of lost or unavailable  2. diagnostic quality images radiographs

 3. written radiographic report that comes to a diagnostic  communication with other health care providers conclusion  patient care through providing a list of important indications  4. incorporation of imaging findings in the patient and contraindications for treatment record/chart.

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Minimum Two views; Radiology Report Structure Perpendicular

 These are the components that make up the radiology Two projections at 90 report; degree orientation to each  patient information: name, D.O.B., sex, file number other is the minimum radiographic series. By  radiographic information: views, dates and where taken having two projections  technical information (optional in report); keep as log book oriented perpendicular to one another, one can gain  Useful for dose computations and re-takes/ re-examinations a 3 dimensional perspective of the  report structure includes: AP Lumbar anatomy.  paragraph of radiologic findings. Motorcycle collision.  List diagnostic impressions Can you find the  recommendations problem on this  signature and qualifications projection?

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6 8/30/2019

Minimum Two views; Perpendicular LMP Fracture/Dislocation of L1. Note anterior dislocation of the superior endplate of L1  Last Menstrual Period relative to the remainder the vertebral body. Get the date of LMP on all menstruating females before x-ray procedures are performed. Additional information from 200 mrad of exposure for lumbar study. the second projection taken from a different perspective Fetal dose limit for occupational workers of 500 mrad. can be invaluable. Dose for “therapeutic abortion” is over 5 rads.

Lateral Lumbar

37 38

 Mr. Wilson  Recurrent LBP  Low back pain  Leg pain with walking  “Catch/click” with lying prone

39 40

Flexion Extension Recumbent Recumbent

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7 8/30/2019

 Neutral Flexion Extension

43 44

Continued pain despite solid arthrodesis

 Multiple reasons for pain / failed surgery syndrome.

 This particular patient has a transitional segment with an acessory joint. Could that be a cause of continued pain? L5/S1 was not included in the fusion.

 Adjacent level disease, or accelerated degeneration of the motion segments above and below the fusion are known causes of failed fusion.

 Incomplete fusion or incomplete incorporation of bone graft material with adjacent vertebra. And hardware failure are known causes of failed surgery syndrome.

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CASE 2; Degen. Spondylo. Case 2; Degen. Spondylo.

53 year old female; weight-bearing x-ray LBP 2 mnth duration following Ty Bo workout. previous LBP and lifting work Left Leg pain to foot with “Zingers”

 Seated flexion and extension lateral lumbar radiographs

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Case 2; Degen. Spondylo. Case 2; Degen. Spondylo.

 L5 pars interarticulares are intact Standing neutral lateral Recumbent flexed lateral Flexion shows reduction of ~8mm = instability 49 50

Case 2; Degen. Spondylo. Case 2; Degen. Spondylo

 T1 and T2 midline sagittal images  Right and Left parasagittal T2 images  Supine/nonweight-bearing MRI  Wide right L4/L5 facet and wide right and left L5/S1 facets. Due  Total reduction of grade II spondylolisthesis to advanced degenerative facet arthrosis with morphologic remodeling of facets, allowing for the grade II anterolisthesis of L5 on S1.  Facet joints are “gapped” with reduction of anterolisthesis. 51 52

 Axial T2 at L5/S1  T2 weighted Axial at L4/L5.  Gapped Facet joints, related to “reduced”  Wide right L4/L5 facet. spondylolisthesis.  Asymmetric facet arthrosis relates to “rotational”  Gap measures ~ 5mm A-P dimension. degen. Spondylolisthesis.

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Standing flexion/ extension positioning does not isolate lumbar motion.

 Standing Neutral Lateral Lumbar Seated flexion/ extension also continues to involve muscular control, limiting segmental movement

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 Passive extension can be done with the patient recumbent, side-lying and then passively moved into extension by the physician/technologist.

 Passive Flexion can be done with the patient recumbent, side-lying and then passively moved into flexion by the physician/technologist.

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Passive flexion/ extension side-lying lateral lumbar projections

 Rationale is to decrease muscular activity and allow intersegmental movement to be discovered.  Panjabi’s theories on muscular activity maintaining stability, rather than stability being maintained by ligaments fits this model.

J Spinal Disord Tech Volume 18, Number 1, February 2005 59 60

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J Spinal Disord Tech Volume 18, Number 1, February 2005

 We report a new method to clearly estimate the spondylolisthesis of lumbar vertebrae.  The ‘‘prone’’ position  Patient positioned in C-Arm  During surgery for a standard lumbar disc herniation in the prone position, we observed a clear slippage of the vertebral segment.

 From that observation, we developed our new technique, evaluating lumbar mobility according to the patient’s position.

 Our method is of interest because it represents a simple and economical procedure for measuring sagittal plane segmental motion of the lumbar spine by conventional lateral x-rays using two lateral radiographic views taken in the supine–prone position instead of extension and flexion.

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Supine / Prone Investigation

 Gould ?  Could evaluation with supine and prone lateral lumbar images reveal more segmental mobility changes compared to standard standing or seated evaluations?

 Could supine / prone evaluation be used in X-ray rooms without a dedicated X-ray Table?

 Can Supine/ prone investigations be performed in the “weightbearing” MRI units?  Some MRI facilities are offering sidelying flex/extension evaluation with patient side lying and sagittal images obtained.

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Lumbar rehab stretches/exercises

Bird dog.

Plank- elbows and toes (more advanced) Plank – elbows and knees (beginner)

Knee-to-chest 1 leg Knee-to-chest both legs

 Strengthen core musculature to influence deep paraspinal muscles.  MacGill; deep paraspinal muscles, abdominal muscles, and lumbodorsal fascia contribute to the muscular girdle to protect the lower back. All on the same neurologic circuit.

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Case #4

 Lower back pain and sciatica

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 Close up AP L

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Findings

 Soft-tissue “fullness” of pelvic basin.

 Urinary bladder shadow is seen inferiorly.

 Question of bowel displacement at superior right portion of pelvic basin.

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Other imaging

 Other imaging or recommendations for further clarification?

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Additional imaging

 Ultrasound

 C.T.

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Differentials

 Soft tissue mass of the pelvis

 Uterine

 Ovarian

 Bowel

 Bladder

 Other

 Obstructive hydronephrosis

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Differentials Differentials

 Gamut H-67 Reeder and Felson’s 3rd ed.  Gamut H-67 Reeder and Felson’s 3rd ed.  Large soft tissue Mass in the Pelvis  Large soft tissue Mass in the Pelvis  Common  Uncommon  Abscess  Bone Tumor (chordoma, Ewing’s, osteosarc.,  Bladder enlargement chondrosarc.  Feces in colon  Extraperitoneal neoplasm (lymphoma, teratoma, spindle cell tumor, rhabdomyosarc., Neurogenic tumor)  Fluid-filled loop of bowl  Hemato – or hydrometrocolpos  Hematoma  Hydatid cyst  Ovarian Cyst or neoplasm  Meningocele, anterior  Pregnancy  Pelvic kidney  Uterine neoplasm (fibroid, mole, carcinoma)  Pelvic lipomatosis

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Diagnosis Treatment

 Ovarian Carcinoma

• And

 Uterine Fibroid

 Pre surg post surg. » -at bladder level and » just above bladder level 87 88

Treatment Discussion

 Plain film findings – not reliable  Uterine enlargement – homogeneous soft tissue density – superior margin is indistinct above the pelvic basin. – Superior indentation of the bladder may be caused by uterine, ovarian and other masses. – Calcification and type of calcification may aid in differentiation of mass.  Pre surg Post surg. Resection of tumor. Hydronephrosis resolved 89 90

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Discussion

 Adenocarcinoma of the uterus

 Most common uterine neoplasm

 Rarely calcifies,

 except after radiation therapy

• Granulosa Cell tumor of the ovary confined to the pelvis. It displaces the bladder roof downward and is indistinguishable from a uterine mass. • From: The Abdominal Plain Film, Stephen Baker, Appleton& Lange, 1990, pg.383.

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Who, What, When Where, Why

 There has been a push to limit imaging on patients. This push is a response to providers ordering imaging without good cause and therefore lowering the “yield” of the studies obtained.

 Patients that present with signs and symptoms that meet and criteria will likely result in higher yield of the imaging studies for positive findings.

 However, there are times when the practitioner needs to order imaging, despite the recommendations. This is the ART of practice. These instances should not be and majority of the time, rather, the minority.

 Imaging for the reason of “that is just how it has always been done is not appropriate”.

 Document what the patient is presenting with and what differentials are possible or to be excluded.

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Mild Traumatic Brain Injury (Concussion) Each year, an estimated 1.7 million people sustain a TBI (concussion) in the United States. Mild Traumatic Brain Injury (mTBI) is a very common sports injury. •15-30% of mTBI patients experience persistent post-concussive symptoms (PPCS). •Decades later (or even sooner) mTBI may lead to neurodegenerative disease. Military Relevance: Since Operation Iraqi Freedom (OIF) and Operation Enduring Freedom MTBI (OEF), the United States Armed Forces has documented more than 300,000 cases of traumatic brain injury (TBI) STEVEN J. GOULD, D.C., D.A.C.B.R. 80-95% are classified as mTBI. mTBI and PTSD share similar symptoms, and both can be present in the same individual.

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Clinical Policy: Neuroimaging and Decisionmakingin Adult Mild Traumatic Brain Injury in the Acute Setting From the MTBI background American College of Emergency Physicians (ACEP)/Centers for Disease Control and Prevention (CDC) Panel to Revise the 2002 Clinical Policy: Neuroimaging and Decisionmakingin Adult Mild Traumatic Brain Injury in the Acute Setting: Although mTBI has long been considered a noncritical injury, serious short and long term effects have been documented. Additionally, there is broad acceptance that multiple mTBIs can have serious long-term consequences. There are more than 1 million emergency department (ED) visits annually for traumatic brain injury (TBI) in the United States.1,2 ▪Two common hypotheses on the etiology of mTBI. The majority of these visits are for “mild” injuries that are primarily the result of falls and motor ▪ 1. Frontal and anterior cortices are vulnerable to neural contusion. vehicle crashes.1,2 ▪2. Linear and rotational forces act on axon bundles, leading to axonal injury. In nonpediatric patients, the highest incidence of mild TBI is seen in males between the ages of ▪After initial injury, secondary mechanisms elicit biochemical, metabolic, and cellular changes in the time frame of 15 and 24 years and in men and women 65 years of age and older.3 minutes, days and months. It has been reported that up to 15% of patients with head trauma evaluated in the ED with a ▪Within the first fifteen minute post-injury, there is an extreme dip in neuropsychological and deficits can often linger for a Glasgow Coma Scale (GCS) score of 15 will have an acute lesion on head computed tomography week or longer. (CT); ▪The definition of the acute time frame varies across publications and some studies report acute periods of up to 1 month less than 1% of these patients will have a lesion requiring a neurosurgical intervention. 4-9 post-injury. Depending on how disability is defined, 5% to 15% of patients with mild TBI may have ▪Others use the term acute mTBI up to two weeks post-injury. Using the term acute or “semi-acute” for time periods up to compromised function 1 year after their injury.10,11 2 weeks post-injury is common in the literature.

C. Eierud et al. / NeuroImage: Clinical 4 (2014) 283–294

Annals of Emergency Medicine Volume 52, No. 6: December 2008 3 4

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The American Congress of Rehabilitation Medicine delineated inclusion criteria for a diagnosis of mild TBI, of Terminology which at least 1 of the following must be met: Terms used have included “concussion,” “mild TBI,” “minor TBI,” “minimal TBI,” “grade I TBI,” “class I TBI,” and “lowrisk TBI.”

Even the terms “head” and “brain” have been used interchangeably. 1. Any period of loss of consciousness of less than 30 minutes and GCS score of 13 to 15 after Head injury and TBI are 2 distinct entities that are often, but not necessarily, related. this period of loss of consciousness; A head injury is best defined as an injury that is clinically evident on physical examination and is 2. Any loss of memory of the event immediately before or after the accident, with posttraumatic recognized by the presence of ecchymoses, lacerations, deformities, or cerebrospinal fluid amnesia of less than 24 hours; or leakage. 3. Any alteration in mental state at the time of the accident (eg, feeling dazed, disoriented, or A traumatic brain injury refers specifically to an injury to the brain itself and is not always confused). clinically evident; if unrecognized, it may result in an adverse outcome.

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The Centers for Disease Control and Prevention has

developed a similar conceptual definition for mild TBI18:

Occurrence of injury to the head, resulting from blunt trauma or acceleration or deceleration Severity Mild Moderate Severe forces, with one or more of the following conditions attributable to the head injury during the surveillance period: Structural imaging; Normal Normal or abnormal Normal or abnormal

● Any period of observed or self-reported transient confusion, Loss of consciousness; 0 to 30 min. > 30 min. and < 24 hours > 24 hours

● Any period of observed or self-reported dysfunction of memory (amnesia) around the time of Alteration of consciousness; a moment up to 24 hours > 24 hours severity based on injury other criteria

● Observed signs of other neurologic or neuropsychological dysfunction Post traumatic amnesia; 24 hours > 24 hours and < 7 days > 7 days

● Any period of observed or self-reported loss of consciousness lasting 30 minutes or less.

Both definitions are broad and contribute to the difficulty of interpreting the mild TBI literature.

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Concussion video https://www.youtube.com/watch?v=tgChTeALF7g References/ Sources: CDC: Heads Up Program https://www.cdc.gov/headsup/ ◦Kansas Sports Concussion Partnership http://www.kansasconcussion.org/

KSHSAA: http://www.kshsaa.org/Public/General/ConcussionGuidelines.cfm

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GCS Clinical Assessment A single GCS determination cannot be used solely in diagnosing mild TBI. Sports concussion. In one of the original multicenter studies validating the scale in the pre-CT era, On field assessment: approximately 13% of patients who became comatose had an initial GCS of 15. GCS of 14 -15 used for determination of mTBI. Head or neck injury or concussion suspected. Those below 13 are of greater risk for injury requiring neurosurgical ◦Evaluate at point of injury beginning with ABCs. consultation. ◦R/O Serious C. spine injury ◦Sideline assessment tool for concussion

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Types of injury SCAT5 TBI SCAT 5 for individuals age 13 and over. ◦MTBI, Moderate, and Severe ◦Contusion Child SCAT5 for ages 5 -12. ◦Hematoma: ◦ Subdrual ◦ Epidural

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Cerebral hemorrhagic contusions are a type of intracerebral hemorrhage and are Contusion common in the setting of significant head injury. They are usually characterized on CT as hyperdense foci in the frontal lobes adjacent to the floor of the anterior cranial CT: fossa and in the temporal poles. In most hospitals, CT is usually the first and often the only investigation used to assess cerebral contusions. Sensitivity to detect intracerebral hemorrhage on CT scans is virtually 100%. Epidemiology : Contusions, by definition, result from head trauma and are thus seen more frequently in young Hounsfield units(HU) of blood are dependent on protein concentration (i.e. hemoglobin) and hematocrit. males. Typical causes include motor vehicle accidents (MVA) or situations in which the head strikes the pavement. With a hematocrit of 45% the density of whole blood is ~56 HU while the grey matter is 37-41 HU and white matter is 30-34 HU. So blood should be hyperdense in comparison to grey or white matter. Pathology: Most contusions represent the brain coming to a sudden stop against the inner surface of the skull Of note, in anemic patients (i.e. hemoglobin < 8-10 g/dL) blood may appear isodense in an acute bleeding. (coup -contrecoup) accentuated by the natural contours of the skull. Contusions vary in size and can appear as small petechial foci of hyperdensity / hemorrhages involving the grey matter and subcortical white matter or large cortical/subcortical bleed. Radiographic features : Cerebral contusions can occur anywhere, but have a predilection for certain locations, as a result of the direction of the head strike and the intrinsic shape of the skull cavity. MRI: Although not often used merely for the assessment of superficial contusions, MRI is far more •floor of the anterior cranial fossa / temporal lobe / coup and contre coup pattern sensitive to small contusions, especially whenT2*sequences, i.e. SWI, are used. Typically cortical contusions become more apparent on follow-up imaging due to further bleed or surrounding Signal behaviour is strongly dependent on sequence and time since the bleeding started. edema. Hence on follow-up CT scans in the first couple of days after trauma, one may detect the increase in number and size of the lesions but the patient may not show any clinical deterioration. Practical pearls and pitfalls A pitfall is missing a small contusion near the skull base, which can be overseen on CT scans due to partial volume Furthermore, the appearance of contusions will vary according to when they are imaged. Typically they mature artefact. over some weeks, initially appearing as merely hemorrhagic foci, followed by the development of surrounding edema, before gradually fading away leaving behind more or less distinct areas of gliosis.

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Small contusion Referral to Dr. Hubbard

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Vestibular/Ocular-Motor Screening (VOMS) for Concussion Mucha A, Collins MW, Elbin RJ, Furman JM, Troutman-Enseki C, DeWolf RM, Marchetti G, Kontos AP. A brief vestibular and ocular motor screening (VOMS) assessment to evaluate preliminary concussion: Preliminary findings. Am J Sports Med; in press. video

Vestibular/Ocular Motor Screening (VOMS) assessment, which http://rethinkconcussions.upmc.com/2016/10/what-is-voms/ included 5 domains: (1) smooth pursuit, (2) horizontal and vertical saccades, (3) near point of convergence (NPC) distance, (4) horizontal vestibular ocular reflex (VOR), and (5) visual motion sensitivity (VMS). http://rethinkconcussions.upmc.com/2016/10/what-is-voms/

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Results: Sixty-one percent of patients reported symptom provocation after at least 1 VOMS item. (vestibular ocular motor screens)

Conclusion: The VOMS demonstrated internal consistency as well as sensitivity in identifying patients with concussions. All VOMS items were positively correlated to the PCSS total symptom The current findings provide preliminary support for the utility of the score. VOMS as a brief vestibular/ocular motor screen after sport-related (PCSS= post concussion symptom scale) concussions. The VOMS may augment current assessment tools and may serve as a single component of a comprehensive approach to the assessment An NPC (near point convergence) distance >5 cm and any VOMS item of concussions. symptom score 2 resulted in an increase in the probability of correctly identifying concussed patients of 38% and 50%, respectively.

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Smooth Pursuits - Test the ability to follow a slowly moving target. The patient and the examiner are seated. The examiner holds a fingertip at a distance of 3 ft. from the patient. The patient is Smooth Pursuits instructed to maintain focus on the target as the examiner moves the target smoothly in the horizontal direction 1.5 ft. to the right and 1.5 ft. to the left of midline. One repetition is complete when the target moves back and forth to the starting position, and 2 repetitions are performed. The target should be moved at a rate requiring approximately 2 seconds to go fully from left to right and 2 seconds to go fully from right to left. The test is repeated with the examiner moving the target smoothly and slowly in the vertical direction 1.5 ft. above and 1.5 ft. below midline for 2 complete repetitions up and down. Again, the target should be moved at a rate requiring approximately 2 seconds to move the eyes fully upward and 2 seconds to move fully downward. Record: Headache, Dizziness, Nausea & Fogginess ratings after the test. (Figure 1)

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Saccades – Test the ability of the eyes to move quickly between targets. The patient and the examiner are seated. Horizontal Saccades Horizontal Saccades: The examiner holds two single points (fingertips) horizontally at a distance of 3 ft. from the patient, and 1.5 ft. to the right and 1.5 ft. to the left of midline so that the patient must gaze 30 degrees to left and 30 degrees to the right. Instruct the patient to move their eyes as quickly as possible from point to point. One repetition is complete when the eyes move back and forth to the starting position, and 10 repetitions are performed. Record: Headache, Dizziness, Nausea & Fogginess ratings after the test. (Figure 2)

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Vertical Saccades Vertical Saccades: Repeat the test with 2 points held vertically at a distance of 3 ft. from the patient, and 1.5 feet above and 1.5 feet below midline so that the patient must gaze 30 degrees upward and 30 degrees downward. Instruct the patient to move their eyes as quickly as possible from point to point. One repetition is complete when the eyes move up and down to the starting position, and 10 repetitions are performed. Record: Headache, Dizziness, Nausea & Fogginess ratings after the test. (Figure 3)

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NPC = Near point convergence NPC – Near Point Convergence (~5cm) Convergence – Measure the ability to view a near target without double vision. The patient is seated and wearing corrective lenses (if needed). The examiner is seated front of the patient and observes their eye movement during this test. The patient focuses on a small target (approximately 14 point font size) at arm’s length and slowly brings it toward the tip of their nose. The patient is instructed to stop moving the target when they see two distinct images or when the examiner observes an outward deviation of one eye. Blurring of the image is ignored. The distance in cm. between target and the tip of nose is measured and recorded. This is repeated a total of 3 times with measures recorded each time. Record: Headache, Dizziness, Nausea & Fogginess ratings after the test. Abnormal: Near Point of convergence ≥ 6 cm from the tip of the nose. (Figure 4)

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VOR Vestibular-Ocular Reflex (VOR) Test – Assess the ability to stabilize vision as the head moves. The patient and the examiner are seated. The examiner holds a target of VOR - horizontal approximately 14 point font size in front of the patient in midline at a distance of 3 ft. Horizontal VOR Test: The patient is asked to rotate their head horizontally while maintaining focus on the target. The head is moved at an amplitude of 20 degrees to each side and a metronome is used to ensure the speed of rotation is maintained at 180 beats/minute (one beat in each direction). One repetition is complete when the head moves back and forth to the starting position, and 10 repetitions are performed. Record: Headache, Dizziness, Nausea and Fogginess ratings 10 sec after the test is completed. (Figure 5) Vertical VOR Test: The test is repeated with the patient moving their head vertically. The head is moved in an amplitude of 20 degrees up and 20 degrees down and a metronome is used to ensure the speed of movement is maintained at 180 beats/minute (one beat in each direction). One repetition is complete when the head moves up and down to the starting position, and 10 repetitions are performed. Record: Headache, Dizziness, Nausea and Fogginess ratings after the test. (Figure 6)

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https://www.youtube.com/watch?v=PJLv VOR - vertical 5zdmEns Visual Motion Sensitivity (VMS) Test – Test visual motion sensitivity and the ability to inhibit vestibular-induced eye movements using vision. The patient stands with feet shoulder width apart, facing a busy area of the clinic. The examiner stands next to and slightly behind the patient, so that the patient is guarded but the movement can be performed freely. The patient holds arm outstretched and focuses on their thumb. Maintaining focus on their thumb, the patient rotates, together as a unit, their head, eyes and trunk at an amplitude of 80 degrees to the right and 80 degrees to the left. A metronome is used to ensure the speed of rotation is maintained at 50 beats/min (one beat in each direction). One repetition is complete when the trunk rotates back and forth to the starting position, and 5 repetitions are performed. Record: Headache, Dizziness, Nausea & Fogginess ratings after the test. (Figure 7)

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Cerebral hemorrhagic contusion with Cerebral hemorrhagic contusion with subdural and subarachnoid hemorrhage subdural and subarachnoid hemorrhage

50 year old male who fell 3 meters 50 year old male who fell 3 meters

CT demonstrates extensive left frontal CT demonstrates extensive left frontal and to a lesser degree left temporal lobe and to a lesser degree left temporal lobe hemorrhagic contusions with overlying hemorrhagic contusions with overlying acute subdural and subarachnoid blood. acute subdural and subarachnoid blood. Bone window demonstrates extensive Bone window demonstrates extensive undisplaced occipital fractures. undisplaced occipital fractures. Case courtesy of A.Prof Frank Gaillard, Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 10680 Radiopaedia.org, rID: 10680

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MRI: Flair and SWI images: Patient was riding her bicycle when she was hit by a car and smashed the windshield with the back of her head. MTBI C.T. FLAIR SWI BLOOD HYPERDENSE WATER HYPERINTENSE SUSEPTIBILITY WEIGHTED mTBI is difficult to diagnose and characterize: LIKE GRE IMAGE (HEMOBLOBIN) ◦ CT and conventional MRI are not optimal for detecting subtle injuries. ◦ Disorder is very heterogeneous (various vectors of trauma), difficult to study with standard population techniques. Advanced neuroimaging is useful for diagnosis and prognosis. ◦ Diffusion imaging has shown good sensitivity to detect brain alterations in living individuals with mTBI. ◦ Subject-Specific analyses are best suited to study brain injuries.

Case courtesy of DrSajoschaSorrentino, Radiopaedia.org. From the case rID: 16409 47 48

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Clinical decisions: When to image following trauma;

JAMA. 2005;294:1511-1518 www.jama.com 49 50

Comparison of the Canadian CT Head Rule and the New Canadian CT Head Rule* Computed tomography is only required for Orleans Criteria in Patients With Minor Head Injury patients with minor head injury with any 1 of the following findings: Patients with minor head injury who present with a Glasgow Coma Scale score of 13 to 15 after witnessed loss of Results: consciousness, amnesia, or confusion. 1822 patients with GCS score of 15, High Risk for Neurosurgical Intervention 8 (0.4%) required neurosurgical intervention and 1. Glasgow Coma Scale score lower than 15 at 2 hours after injury 97 (5.3%) had clinically important brain injury. The NOC and the CCHR both had 100% sensitivity but the CCHR was more specific (76.3% vs 12.1%, P.001) for predicting 2. Suspected open or depressed skull fracture need for neurosurgical intervention. For clinically important brain injury, the CCHR and the NOC had similar sensitivity (100% vs 100%; 95% confidence interval [CI], 96%-100%) but the CCHR was more specific (50.6% vs 12.7%, P.001), and 3. Any sign of basal skull fracture† would result in lower CT rates (52.1% vs 88.0%, P.001). The values for physician interpretation of the rules, CCHR vs NOC, were 0.85 vs 0.47. Physicians misinterpreted the rules as not requiring imaging for 4.0% of patients according to CCHR and 5.5% according to NOC (P = .04). Among all 2707 patients with a GCS score of 13 to 15, the CCHR had sensitivities of 4. Two or more episodes of vomiting 100% (95% CI, 91%-100%) for 41 patients requiring neurosurgical intervention and 100% (95% CI, 98%-100%) for 231 patients with clinically important brain injury. 5. 65 years or older Conclusion: Medium Risk for Brain Injury Detection by Computed Tomographic Imaging For patients with minor head injury and GCS score of 15, the CCHR and the NOC have equivalent high sensitivities for need for neurosurgical intervention and clinically important brain injury, but the CCHR has higher specificity for 6. Amnesia before impact of 30 or more minutes important clinical outcomes than does the NOC, and its use may result in reduced imaging rates. 7. Dangerous mechanism‡ *The rule is not applicable if the patient did not experience a trauma, has a Glasgow Coma Scale score lower than 13, is younger than 16 years, is taking warfarin or has a bleeding disorder, or has an obvious open skull fracture. †Signs of of basal skull fracture include hemotympanum, racoon eyes, cerebrospinal fluid, otorrhea or rhinorrhea, Battle’s sign. ‡Dangerous mechanism is a JAMA. 2005;294:1511-1518 www.jama.com pedestrian struck by a motor vehicle, an occupant ejected from a motor vehicle, or a fall from an elevation of 3 or more feet or 5 stairs. 51 52

NOC New Orleans Criteria Computed tomography is required for patients with minor head injury with any 1 of the following findings. The criteria apply only to patients who also have a Glasgow Coma Scale score of 15. 1. Headache 2. Vomiting 3. Older than 60 years 4. Drug or alcohol intoxication 5. Persistent anterograde amnesia (deficits in short-term memory) 6. Visible trauma above the clavicle 7. Seizure

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Acute Traumatic Brain Injury Acute Traumatic Brain Injury MRI used in cases where CT results do not correlate with clinical findings in acute setting. Acute Traumatic Brain Injury: MRI has higher sensitivity for detecting diffuse axonal injury (DAI). CT and MRI are utilized. CT is the primary modality due to shorter scan times, MRI favored over CT for evaluation of patients with persistent symptoms in the subacute or chronic ability to tolerate life support equip., availability, and accurately detect setting. neurosurgical emergencies. MRI techniques such as diffusion-weighted imaging (DWI), T2*-weighted gradient recalled echo (GRE), susceptibility-weighted imaging (SWI), and T2-weighted Fluid attenuated inversion recovery CT has 99.7% negative predictive value in excluding neurosurgical emergencies. (T2W FLAIR) are used in clinical practice. T2W FLAIR has increased sensitivity in detecting subarachnoid hemorrhages, Brain contusions, and Multiple criteria have been developed to determine necessity of CT in MTBI brainstem injuries, compared to non-contrast CT. cases. (Canadian CT Head rule and New Orleans criteria). T2*GRE and SWI detect microhemorrhages, diffuse axonal injuries, and subacute/chronic hemorrhages better than CT. New Orleans criteria has been shown to be 100% sensitive for detecting injuries that require neurosurgical intervention. SWI detects microhemorrhages better than T2*GRE but can over-estimate extent of hemorrhage

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Dr Scharenberg case: Neck pain.

A case of “radiophobia”

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Methodologies Additional Neuroimaging;

Morphometry

Genetics PET

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Diffusion Weighted Imaging and Diffusion Tensor Imaging Movement of water through tissues…. Diffusion, or Brownian movement, denotes the random motion of molecules. All molecules exhibit such motion at temperatures greater than absolute zero. Diffusion is termed isotropic if the motion is equal in all directions. However, water diffuses asymmetrically in the white matter—that is, diffusion is restricted Diffusion Imaging perpendicular to the long axis of the axons. By contrast, water diffuses faster along the Z axis. This property is known as anisotropy; Functional Imaging it may be used to define the direction of the axons in a particular voxel

MR Spectroscopy

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DWI Diffusion Tensor Imaging Axial DWI image demonstrates a typical wedge-shaped, cortical- based, hyperintense lesion in the Fundamentals left temporoparietal lobes consistent with acute infarct.

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DTI Fractional Anisotropy 1827 - Robert Brown observes movement of plant spores floating in water. A summary measure derived from DTI, which describes the directional 1905 - Albert Einstein gives the first satisfactory theoretical treatment of Brownian motion. coherence (anisotropy) of water diffusion within tissue. However, mean diffusivity, axial diffusivity, and radial diffusivity may more specifically describe 1965 - Stejskal and Tanner develop the experimental method to detect water diffusion in living the direction and magnitude of tissue water diffusion. tissue. 1986 - Le Bihan introduces Diffusion MR Imaging. 1995 - Basser develops a method to obtain DTI and to quantify diffusion. Animal studies have shown direct correspondence between even very sutle TAI pathology and decreased in white matter anisotropy that can be imaged in vivo 1996 - Pierpaoli - first DTI application to human brain. using DTI. 1998 - Buchsbaum - first DTI study of schizophrenia. 2002 - Arfanakis - first DTI study of TBI.

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Water Diffusion in the Brain has Directionality DTI

• At each location, the diffusion behavior of water is modeled as an ellipsoid. • In medical imaging this ellipsoid is called a diffusion tensor.

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Anisotropy DTI Derived Measures Isotropic = diffusion in all directions ◦ example: analogy: x-ray are emitted in an isotropic fashion from the anode of the x-ray tube. Fractional Anisotropy

Anisotropy ◦ Analogy: fiber optic cable - light goes through the cable in one direction - parallel to the cable = anisotropy because it is directionally dependent and not “isotropically distributed”.

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From Tensors to Tracts Full Brain Tractography

Streamlines are not axons, only macroscopic structure of white matter bundles. Voxel size: mm Axon diameter: • Associate the major diffusion direction with the tangent to a curve. micrometers. • Estimate the curve from its tangents.

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Beyond Diffusion Tensor Imaging Multi-Tensor Tractography

Resolving Crossing Fibers

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Beyond Diffusion Tensor Imaging Neuroinflammation in First Episode Schizophrenia Disrupted connectivity in white matter (WM) neural circuits may explain many of the symptoms of schizophrenia, including delusions, disordered thought and speech, emotional and behavioral deficits, and hallucinations. Multi-Shell Diffusion Imaging •Myelin alteration: Reduced oligodendrocyte counts. Decreased amount of macromolecules in WM. Abnormal expression of genes involved in myelin production. •Neuroinflammation: Increased cytokines, Reduced risk of psychosis following treatment with Glucocortico- steroids Increased binding potential of a microglia (PET). DTI finds widespread decreased FA (red) and increased MD (blue) – Do these findings suggest widespread myelin deficiencies in first episode schizophrenia? MD = myelin deficiency. FA = Fractional anistropy

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Neuroinflammation in First Episode Schizophrenia Diffusion Tensor Imaging and Mild Traumatic Brain Injury All FAT findings are in the frontal lobe. Coincides with the frontal findings in the literature. •Fibers in the frontal lobe are myelinated late, thus could be more vulnerable to inflammation. Chronic mTBI •Chronic Inflammation might cause degeneration in a neurodegenerative pattern. Early detection and treatment with inflammation suppressing drugs could potentially reduce, or prevent the symptoms. Free-water imaging reveals that excessive extracellular volume (blue) explains most group differences, suggesting widespread neuroinflammation and localized axonal degeneration.

(Pasternak et al., J. Neuroscience 2012) 77 78

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MTBI •mTBI is difficult to diagnose and characterize: Subject-Specific Abnormality Map •CT and conventional MRI are not optimal for detecting subtle injuries. DTI atlas construction. •Disorder is very heterogeneous, difficult to study with standard population techniques. •Advanced neuroimaging is useful for diagnosis and prognosis. •Diffusion imaging has shown good sensitivity to detect brain alterations in living individuals with mTBI. Patient to atlas comparison •Subject-Specific analyses are best suited to study brain injuries.

(Bouix, Pasternak et al., Plos One, 2013) 79 80

Diffusion Tensor Imaging and Mild Traumatic Brain Injury Professional Football: Cortical thickness Pronounced cortical thinning with age in former professional football players

Sports Concussions

▪ Comparison between former professional football players and athlete controls. •NFL players show pronounced cortical thinning with increasing age. •Cortical thinning may indicate abnormal aging and risk for dementia.

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Ice Hockey: Diffusion Tensor Imaging Soccer: Brain Changes Following Subconcussion

Abnormalities in the brain‘s microstructure in ice Hockey players Abnormalities in Soccer Players without history of concussion •Preseason versus postseason evaluation. •Elite soccer players versus swimmers. •Postseason scans show higher mean diffusivity – more space between axons. •Participants who suffered from concussion during the season are in red. •Soccer players show higher radial diffusivity – reduced myelin sheath. (Koerte et al., JAMA 2012) 83 84

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Metabolite Profiles in Chronic Sports-Related MR Spectroscopy: The Virtual Biopsy Concussion N-Acetyl aspartate - Neuronal Marker NAA Creatine - energy marker Increases in Cho in retired NFL players. Choline - membrane Marker Cr Choline increase or changes with Myo-inositol - Glial Marker cellular membrane disruption. mI Cho Gluathione - Anti –oxidant Glx

Gluamate - Neurotransmitter

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PET

Diffusion tensor imaging. (A) Reconstructed fractional anisotropy (FA) map demonstrates regions of high-ordered water motion (high FA) as red and more random water motion (low FA) as blue. (B) Three-dimensional white matter tractrogram of the intact corticospinal tract generated from the diffusion tensor imaging data.

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Imaging Evidence and Recommendations for Traumatic Brain Injury: Advanced Neuro-and Neurovascular Imaging Techniques

CONCLUSIONS A number of advanced neuroimaging techniques are currently under investigation in an attempt to optimize them and substantiate their clinical relevance in individual patients; however, the data currently available confine their use to the research arena for group comparisons. TBI imaging is a rapidly evolving field, and a number of the recommendations presented will be updated in the future to reflect the advances in medical knowledge.

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The first week after concussion: Blood flow, brain function and white matter microstructure NathanW. Churchilla,, NeuroImage: Clinical14 (2017) 480–489

ABSTRACT: Concussion is a major health concern, associated with short-term deficits in physical function, emotion and cognition, along with negative long-term health outcomes. However, we remain in the early stages of characterizing MRI markers of concussion, particularly during the first week post-injury when symptoms are most severe. In this study, 52 varsity athletes were scanned using Magnetic Resonance Imaging (MRI), 26 athletes with acute concussion (scanned 1–7 days post-injury) 26 matched control athletes. A comprehensive set of functional and structural MRI measures were analyzed, including cerebral blood flow (CBF) and global functional connectivity (Gconn) of grey matter, along with fractional anisotropy (FA) and mean diffusivity (MD) of white matter. An analysis comparing acutely concussed athletes and controls showed limited evidence for reliable mean effects of acute concussion, with only MD showing spatially extensive differences between groups

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The first week after concussion: Blood flow, brain function and white matter microstructure NathanW. Churchilla,, NeuroImage: Clinical14 (2017) 480–489

We subsequently demonstrated that the number of days post-injury explained a significant proportion of inter-subject variability in MRI markers of acutely concussed athletes. Athletes scanned at early acute injury (1–3 days) had elevated CBF and Gconn and reduced FA, Those scanned at late acute injury (5–7 days) had the opposite response. In contrast, MD (mean diffusivity) showed a more complex, spatially-dependent relationship with days post-injury. These novel findings highlight the variability of MRI markers during the acute phase of concussion and the critical importance of considering the acute injury time interval, which has significant implications for studies relating acute MRI data to concussion outcomes. © 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY- NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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Despite the cross-sectional nature of this study, our findings are consistent with post-injury brain changes mapped out in rodent models, and therefore support The results of this study show an effect of days post-injury that is consistent with the the presence of similar physiological processes in humans. In both animal neurometabolic cascade seen in rodent models (Giza and Hovda, 2001; Giza and Hovda, models and our current findings, an early period of hyper-metabolic activity and 2014). hyper-perfusion is observed, followed by an interval of depressed neural activity and hypo-perfusion (Giza and Hovda, 2001; Giza and Hovda, 2014). However, we emphasize that in humans this cannot be entirely separated from physical factors such as reduced physical and mental exertion, as this is a part of the consensus This is of particular interest to future studies, as it may reflect the emergence of concussion management guidelines during the symptomatic phase of injury (McCrory et a delayed period of “metabolic vulnerability” described in (Vagnozziet al., 2008), al., 2013). which is critical to avoid when establishing safe return-to-play for athletes Athletes in the present study are recommended to avoid strenuous exercise but may following concussion. otherwise perform daily activities, which may mitigate the detrimental effects of Future studies should investigate these effects in greater detail, with multiple prolonged rest (see, for example, (Silverberg and Iverson, 2013)). scans at well-defined post-injury intervals. Future concussion research should examine this issue, by comparing athletes, who significantly reduce physical exertion following concussion, to non-athlete cohorts.

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Chronic Traumatic Encephalopathy (CTE) Pathologic dx. 3 categories of clinical symptoms. Cognition: Cognitive symptoms: memory, speech, executive dysfunction. Mood: Mood changes: depression, apathy, suicidality. Behavior: aggression, increased violence, disinhibition.

◦ Younger groups may show more mood and behavioral changes ◦ Older groups may show more cognitive symptoms. ◦ Parkinsonism and speech changes may accompany other symptoms. ◦ Small subset of cases have been report with a syndrome that mimics ALS. ◦ Moderate TBI has been shown to be a risk for Alzheimer Disease.

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CTE CTE First report in boxers in 1973. Gross pathology: Generalized atrophy- more pronounced in the frontal and medial temporal lobes, thalamus, First case reported from the NFL in 2005. hypothalamus, and mammillary bodies; thinning of the corpus callosum; enlargements of the lateral and third ventricles; and pallor of the substantia nigra and locus coeruleus. Cavum septi pellucidi is Seen in multiple sports: boxing, football, hockey, soccer, wrestling. also a frequently described finding. Microscopic appearance of CTE. Seen in veterans exposed to blast injuries. Accumulation of phosphorylated tau neurofibrillary tangles, neuritis, and glial tangles throughout the frontal, temporal, and insular corticies; diencephalon; brainstem; dentate nucleus; and spinal cord. Seen in pts with self injurious behavior ( such as head banging). Specific distribution of Tau is a distinguishing factor in CTE from AD and other tauopathies. Areas of Neurofibullary tangles usually cluster in areas associated with direct mechanical trauma. Ischemia may be lead to tau deposits in the depths of the sulci. Tau around blood vessels may be associated with breakdown of blood-brain barrier after injury.

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Post-Mortem Tauopathy in a Professional Football Player (Ann McKee et al., 2009)

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CTE CTE No studies today to confirm that MTBI or other condition causes Cannot be diagnosed by imaging. CTE. Many confounding factors in published cases. Acute and chronic head trauma findings on structural imaging are well established. It is unknown what threshold of impact, rotational, or deceleration forces are needed to generate a concussion. Not known if a certain number of concussive or subconcussive injuries predispose to developing CTE. Head trauma alone may not be sufficient to cause CTE

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Acute Traumatic Brain Injury Acute Traumatic Brain Injury MRI used in cases where CT results do not correlate with clinical findings in acute setting. Acute Traumatic Brain Injury: MRI has higher sensitivity for detecting diffuse axonal injury (DAI). CT and MRI are utilized. CT is the primary modality due to shorter scan times, ability to tolerate MRI favored over CT for evaluation of patients with persistent symptoms in the subacute or chronic life support equip., availability, and accurately detect neurosurgical emergencies. setting. CT has 99.7% negative predictive value in excluding neurosurgical emergencies. MRI techniques such as diffusion-weighted imaging (DWI), T2*-weighted gradient recalled echo (GRE), susceptibility-weighted imaging (SWI), and T2-weighted Fluid attenuated inversion recovery Multiple criteria have been developed to determine necessity of CT in MTBI cases. (Canadian CT (T2W FLAIR) are used in clinical practice. Head rule and New Orleans criteria). T2W FLAIR has increased sensitivity in detecting subarachnoid hemorrhages, Brain contusions, and New Orleans criteria has been shown to be 100% sensitive for detecting injuries that require brainstem injuries, compared to non-contrast CT. neurosurgical intervention. T2*GRE and SWI dectect microhemorrhages, diffuse axonal injuries, and subacute/chronic hemorrhages better than CT. SWI detects microhemorrhagesbetter than T2*GRE but can over-estimate extent of hemorrhage

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Subdural and Epidural Hematoma Epidural and subdural hematomas. (A) Axial Subdural hematoma: Bleeding/hemorrhage beneath the dura. computed tomography (CT) demonstrates a Will show more fusiform shape when blood pushed brain tissue from hyperdense lentiform extra-axial epidural hematoma the skull surface, due to the bleed traveling beneath the dura and (short arrow) overlying the right frontal lobe with depressed bone fragments from an overlying pushing on the brain tissue directly. comminuted calvarial fracture. Mass effect from the Epidural hematoma: Bleeding between the skull and the dura epidural hematoma caused leftward subfalcine (bleeding above the dura). herniation (long arrow). Gives a sharply tapered appearance, due to attachment of the dura (B) Axial CT in a different patient demonstrates a to the skull, except where the blood has pushed the blood away hyperdense left hemispheric convexity crescentic from the bone. subdural hematoma (short arrows) causing ventricular effacement and rightward subfalcine herniation (long arrow).

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Acute cerebral contusion in a confused patient Cerebral Contusion with severe traumatic brain injury.

(A) Axial computed tomography (CT) scan demonstrates a right frontal cortical and subcortical hyperdense acute hemorrhagic contusion with surrounding hypodense vasogenic edema. (B) The coronal T2-weighted FLAIR (fluid attenuated inversion recovery) performed shortly after the CT scan better delineates the size and extent of this acute hemorrhagic brain contusion and the extensive surrounding vasogenic edema (arrows). The anteroinferior right frontal lobe, overlying the right orbital roof, is a common location for cerebral contusions.

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Coup - Contrecoup

Multifocal acute cerebral contusions. (A) Diffusion-weighted imaging demonstrates foci of restriction diffusion within the left anteroinferior left frontal lobe (short arrow). (B) T2-weighted FLAIR (fluid attenuated inversion recovery) demonstrates associated abnormal parenchymal hyperintensity consistent with vasogenic edema within the left frontal lobe, site of the “coup” injury (short arrow), and within the right temporal lobe, site of the “contrecoup” injury (long arrow). (C) Susceptibility-weighted imaging demonstrates multiple foci of low signal intensity (short arrow) related to hemorrhage in the left anteroinferior frontal lobe.

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DAI -Diffuse Axonal Injury

Diffuse axonal injury (DAI)is a severe parenchymal traumatic insult seen in closed head injuries and is potentially a difficult diagnosis to make on imaging (especially on CT). It can result in severe neurological impairment. Pathology It is best approached on MRI where it is characterized by small regions of susceptibility artifact at the Diffuse axonal injury is the result of shearing forces, typically from rotational grey-white matter junction, in the corpus callosum, and in more severe cases in the brainstem. acceleration (although this is most often in the form of what lay people would refer to Epidemiology as deceleration, from a physics point of view there is no such thing; all changes in velocity are acceleration). Due to the slightly different specific gravities (relative mass The patients at risk of DAI belong to the same cohort as those who suffer traumatic brain injury and as such young men are very much over-represented. per unit volume)of white and grey matter, shearing due to change in velocity has a predilection for axons at the grey-white matter junction, as the name implies. In Clinical presentation majority of cases these forces result in damage to the cells in a way that cause cell Typically patients who are shown to have DAI, have loss of consciousness at the time of the accident. edema. Actual tear of the axons is rare and only seen in very severe cases. Post-traumatic coma may last variable time, and is often attributed to coexistent more visible injury (e.g.cerebral contusions). As such the diagnosis is often not suspected until later when patients fail to recover neurologically as expected. http://radiopaedia.org/cases/diffuse-axonal-injury-4

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Note the thinning of the corpus DAI callosum (top left in red) in the http://pnl.bwh.harvard.edu/portfolio-item/traumatic-brain-injury-2/ Traumatic Brain Injury patients compared with the Healthy Control …Of particular note here, TBI is the signature injury of soldiers returning from Iraq and on the right. Afghanistan, with 59% of the soldiers treated at Walter Reed Hospital being diagnosed with TBI (80% of the cases are “mild”). The most common brain injury is “diffuse axonal injury”, which involves injury to white matter in the brain, or to the cables that connect Note also the 3D reconstruction of neurons in the brain, with neurons being gray matter in the brain, and thought to be the the fiber bundles of the corpus processing centers of the brain. There are difficulties, however, in diagnosing mild cases callosum on the bottom panel of TBI because computerized tomography (CT), and conventional magnetic resonance which shows fewer fiber bundles in imaging (MRI) are not able to detect diffuse axonal injury and these measures thus end the TBI patient (bottom left) up underestimating injuries and are poorly correlated with outcome. Additionally TBI compared with the Healthy Control and PTSD share similar symptoms and both can be present in the same individual. One (bottom right). study, in fact, shows a 43.9% overlap between the two disorders.

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Mechanism of injury in DAI DAI

This young man was involved in a high speed MVA with a closed head injury and has been slow to rehab.

Case courtesy of A.ProfFrank Gaillard, From the case rID: 5221

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Treatment: Conventional concussion tx: mostly rest: Nutrition: Chiropractic care: recent article for care of cervicogenic components.

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The role of the cervical spine in post-concussion syndrome

One proposed mechanism for persisting symptomatology that has not been Studies examining whiplash associated disorders (WAD) have demonstrated two examined in great detail is concomitant low grade sprain–strain injury of the very important features for our discussion: cervical spine occurring concurrently with significant head trauma. 1) biomechanical studies have demonstrated that as little as 4.5g of neck Anatomical association with head injury to neck injury…… acceleration can cause mild strain injury to the tissues of the cervical spine [19] and Studies in high school and college football players using the Head Impact Telemetry system have demonstrated that the range of linear impact 2) the signs and symptoms reported by these patients, with the exception of a accelerations causing concussion injury is between 60 and 160g (where ‘g’ few key differences (i.e. radicular symptoms), appear strikingly similar to those represents gravity), with the highest predictive occurrence occurring at 96.1g experienced in mTBI(Table 1) [20-28]. [18].

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Pathophysiology of concussion and post-concussion syndrome

During concussive injury to the brain: It is believed that the symptoms of concussion are due to reversible neuronal dysfunction and energy mismatch and not due to structural damage of the involved neurons undergo stretch and shear forces that cause brief mechanical disruption of the cell neurons, which is why conventional structural imaging techniques such as CT and MRI structure, are typically unremarkable [3]. indiscriminate exchange of ions, potassium (K+) efflux, The vast majority of mTBI patients experience a resolution of symptoms within 7–10 glutamate release days following injury [3]. subsequent mitochondrial calcium (Ca2+) overload resulting in impaired oxidative metabolism There are a number of proposed reasons as to why roughly 10–15% of patients go on to and reduced ATP production. experience longer lasting symptomatology, including both physiological and psychological etiology. In an effort to restore proper ion balance within the cell, the ATP pump is activated to a greater capacity requiring large amounts of ATP. Reductions of ATP, continued axonal dysfunction, altered blood flow, continued ANS dysfunction have all been suggested as possible physiological alterations accompanying The imbalance between increased ATP requirements, decreased ATP production and reduced PCS; however, evidence surrounding each of these mechanisms is limited. cerebral blood flow quickly leads to an energy crisis within the brain known as spreading depression (Figure 1) [10,14].

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DX: exclude severe injury Theory 1: Continued metabolic dysfunction Monitoring: Most concussions will resolve with time. Tx: Cervical spine and nutrition need to be considered. No pharmacologic therapies have been Theory 2: Continued axonal dysfunction established. Theory 3: Psychological factors Overall, no medical therapy is usually prescribed for patients after an acute brain injury. Pain control is usually achieved with over-the-counter medications, such as acetaminophen. Avoid Theory 4: Altered cerebral blood flow narcotics so that clouding of the patient's mental status or neurologic examination does not occur. Case for a likely cervicogenic component to concussion injuries In a retrospective study of adolescent patients with concussion, researchers found that overuse of analgesics following injury may exacerbate concussion-related headaches or make them chronic. ◦http://emedicine.medscape.com/article/92095-medication Return to play: No signs/symptoms and pain free activity progression before return to full participation.

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Return to play: Steps to return to play: http://www.kansasconcussion.org/guides/

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http://www.kansasconcussion.org/score-cards/4.php http://www.kansasconcussion.org/score-cards/3.php

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Florida High School Athletic Assoc. ` Initial return form. Another video: https://www.youtube.com/watch?v=8Ke_IIzwDQg functional MRI and DTI (tractography) in practical use; for tumor resection decision making.

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The End

Thank you!

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1 SPRAIN ANKLE IN DRIVEWAY

SPORT AND SPINE CASES

1 2

Medial • AP ANKLE oblique projection.

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1a SOFTBALL SLIDING INJURY MEDIAL OBLIQUE

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1b 2 FOOTBALL INJURY STEPPED ON BY HORSE

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3 FELL IN DRIVEWAY ON ICE AP THUMB

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LATERAL THUMB AP THUMB

LATERAL COLLATERAL LIG AVULSION / GAMEKEEPER’S / SKI POLE INJURY

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4 MALLOT FINGER / BASEBALL FINGER/ EXTENSOR AVULSION

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5 FOOTBALL INJURY SEYMOUR FX

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• http://www.leohanddoc.com/pdf/distal-phalangeal-fingertip-injuries.pdf

• Pediatric Fractures of the Distal Phalanx (Seymour Fracture) A hyperflexion injury to the fingertip in a child is frequently mistaken for a mallet finger. In reality, the extensor tendon is still attached to the proximal dorsal metaphysis of the distal phalanx.6 The deformity is caused by an “open book” flexion fracture of the physis at the proximal end of the distal phalanx. In preadolescents, the fracture is either a Salter-Harris Type 1 or 2; in adolescents, it is generally a Type 3 pattern (Figure 3-11). The diagnosis can be tricky in very small children, younger than 3 years, whose epiphysis may not be calcified. Because the FDP inserts on the distal phalanx distal to the fracture, it acts as a deforming force flexing the distal fragment.

• http://www.boneandjoint.org.uk/content/jbjsbr/48-B/2/347.full.pdf

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BASKETBALL INJURY

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FOOTBALL INJURY SALTER-HARRIS TYPE II 21 22

8 BEFORE WE LEAVE THE FINGERS……

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THE PELVIC DIGIT 9

WRIST PAIN WITH BLOCKING IN FOOTBALL 25 26

SCAPHOID PROJECTIONS:

• Scaphoid fx. cast

Even with special projections, x-ray beam must travel through the fracture line

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10 FELL ON OUTSTRETCHED HAND 10b

LISTER’S TUBERCLE FX

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11 And shoulder pain

JUST HEALED AND RELEASED FROM P.T. FOR LABRAL TEAR AND SURGERY FOR SHOULDER.

NOW TRIPS ON GARAGE STEPS AND FALLS ON CONCRETE FLOOR

Now - Elbow pain

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• Football. Tackled with hand on ground and elbow hyperextended.

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T. ALSTROM • Chronic shoulder pain - off and on. Increased pain lately with weight training.

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• Close up of MRI compared to Sono.

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SHADOWING CALCIFIC LOOSE D. YOUNG BODY NOTED IN MCL • Knee injury. • Planted foot and twisted to reach back and catch a baseball thrown behind him. Cannot extend past ~30 degrees flexion. Non-weightbearing, on crutches.

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ANOTHER KNEE:

• Knee pain • Injury • Prior knee surgery

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• 2nd image sent

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FINDINGS DIFFERENTIALS

• Large joint effusion • New vs. old injuries / previous surgery • ACL Tear • ACL tear • Medial meniscus tear with “double • Meniscus tear PCL sign” • Double PCL is result of meniscus tissue that has been displaced to reside within the intercondylar notch, beneath the intact PCL.

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DIAGNOSIS DISCUSSION • Types of Meniscal tears • Double PCL sign • Oblique or horizontal • Med. Meniscus tear • Vertical • Flap • ACL Tear • Bucket handle • Joint effusion • Peripheral • Medially flipped flap tear • Radial (parrot beak tear) • Meniscocapsular separation – Musculoskeletal MRI: Kaplan, Helms, Dussault, Anderson, Major, 2001 pg. 367 Saunders co.

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DISCUSSION The double posterior cruciate ligament sign. Camacho MA., Radiology. 2004 Nov;233(2):503-4. • Bucket Handle Tear ◼ EARLY IDENTIFICATION OF BUCKET-HANDLE TEARS • Displaced meniscal fragment may IS CRITICAL BECAUSE, ANY DELAY CAN migrate to lie in front of the PCL, COMPROMISE THE CHANCES FOR REPAIR.

producing the appearance of a ◼ IF THE TEAR IS NOT REDUCED, THE MENISCAL “double PCL”. FRAGMENT RISKS FURTHER MACERATION. THESE LESIONS CAUSE SUBSTANTIAL SYMPTOMS, INCLUDING KNEE LOCKING OR A LACK OF FULL EXTENSION.

◼ THE PREVALENCE OF BUCKET-HANDLE TEARS IN – Thanks to Dr. Ray Conley for this SYMPTOMATIC PATIENTS IS 9%–19%

case ◼ ~2:1 RATIO OF MEDIAL-TO-LATERAL INVOLVEMENT IN BUCKET-HANDLE TEARS. 59 60

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The double posterior cruciate ligament sign. THE DOUBLE POSTERIOR CRUCIATE LIGAMENT Camacho MA., Radiology. 2004 Nov;233(2):503-4. SIGN. CAMACHO MA., RADIOLOGY. 2004 NOV;233(2):503-4.

◼ SENSITIVITY OF MR IMAGING FOR • A pitfall of the double PCL sign BUCKET-HANDLE TEARS; • Normal accessory meniscofemoral • ~ 60%–88% ligament • (ligament of Humphry), extends ◼ THE DOUBLE PCL SIGN REMAINS A from the posterior horn of the lateral HIGHLY SPECIFIC INDICATOR OF A meniscus to the lateral aspect of the BUCKET-HANDLE TEAR, WITH A medial femoral condyle SPECIFICITY RANGE OF 98%–100% • The ligament of Humphry is smaller AND A POSITIVE PREDICTIVE VALUE and thinner than the meniscus OF 93%. fragment usually is and ligament is in extremely close proximity to the PCL

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• Another potential pitfall 13 • Oblique meniscomeniscal ligament. • frequency of 1%–4% of general population. • Two variants: noted by their attachment site; FELL ON KNEE • Medial oblique meniscomeniscal ligament originates from the anterior horn of the medial meniscus and inserts into the posterior horn of the lateral meniscus. • Lateral oblique meniscomeniscal ligament originates from the anterior horn of the lateral meniscus and inserts into the posterior horn of the medial meniscus.

• These ligaments traverse the intercondylar fossa, passing between the ACL and PCL, and, may mimic the double PCL sign • To avoid this pitfall, one must trace the course of these ligaments entirely from origin to insertion, as well as confirm the normal morphologic features of the adjacent menisci

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FOOTBALL AND SQUAT HOW ABOUT A LATERAL ! INJURY

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CORTICAL DESMOID CORTICAL DESMOID

• 22 yoa. • Sore medial kee after volleyball. • 3-4 months duration. • No plain films.

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15 Limping gait

DX by PCP as strained hip in soccer.

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Hip pain in volleyball. Cannot run. Referred for X-rays not responding to chiropractic care. 75 76

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Sprinter – felt pain and fell onto track and couldn’t lift the leg after injury.

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GEOGRAPHIC LYTIC LESION PROX. FEM.

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• Knowing what to look for… • Knowing what it means when you see it… • Has research caught up with the significance of a finding?

• Os Acetabulum. Normal variant or indication of a problem?

• AJR 2007; 188:1540–1552

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FEMORAL-ACETABULAR IMPINGEMENT

• Fig. 16—Secondary radiographic signs of femoroacetabular impingement. • A, Recurrent impingement can lead to ossification of labral basis (white arrow) and to osseous apposition of acetabular rim, which is visible as double contour (black arrows) in 45-year-old woman. • B, Because of abnormal stress in impinging hips, prominent acetabular bone fragment can even be separated from adjacent bone margin (os acetabuli, arrow) in 36-yearold an with pistol-grip deformity.

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FEMORAL-ACETABULAR IMPINGEMENT

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New mom – LBP post partum 4 wks.

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LBP FOOTBALL PLAYER

Lower back pain beginning in summer weights and increasing pain with football.

Pain on extension and hop test. Pain with running.

Heparin induced osteoporosis – Levonox tx for prophylaxsis of thrombosis. Hx of prior stroke from contraceptive. Compression fx subsequent to lifting baby. 89 90

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VOLLEYBALL PLAYER SPONDYLOLISTHESIS

Pain through volleyball, worsened with basketball and sought care.

Plain film radiographs obtained due to suspicion of spondylolysis on physical exam and history.

Pain with running. Pain on extension and jumping. Pain on hop test and painful to perform plank exercises. Pain relieved with rest.

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Healing or healed and ununited pars defect.

Does not show high signal change on STIR images,

Not likely to unite with immobilization with lumbar support belt or bracing

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NECK PAIN VOLLEYBALL PLAYER NECK AND UPPER THORACIC PAIN

Pain is severe with warm up and pregame exercise.

Increasing pain but tries to continue to perform activities.

Plain films obtained and deformities revealed.

Orthopedic referral and was told that they have a congenital abnormality.

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FOOTBALL AND WEIGHTS

Cervicothoracic pain. Gaining weight and strength with power lifting and weights for football.

No has severe pain and cannot do exercise now. Extreme pain to palpation at the spinous process C/T junction.

MRI read as unremarkable.

2 rounds of Physical Therapy without relief. RX for 3rd round of PT recommended.

Moved from CA to KS and new DC ordered over read on old MRI study

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LBP AND LEG PAIN

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THROWN FROM HORSE

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END

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