Story of Lumbar Spine: page 1 of 13 1) Variations of Normal
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Goal Objectives Spine is at our Core Central Better a)Illustrate Central Entire skeleton attaches Structural anatomy Structural Flexible understanding Bones Flexible to the spine Anatomy structure & Nerves Anatomy Axial Skeleton Canal & Foramen Spine Radiographs function b)Importance of Radiographs 1.Labeling Spine Radiographs 1.Labeling Head 2.Body Height Lumbar Big Picture 2.Body Height Ribs 3.Alignment Alignment 3.Alignment Appendicular Skeleton Spondylo… Spondylolysis Spondylo… Spondylolisthesis Shoulder girdle Arms
4.Disc Narrow 4.Disc Narrow
c)What Order When Pelvic girdle Legs ACR Approp. ACR ACR Approp. Criteria Criteria www.schreibman.info www.schreibman.info © 2014 Ken L Schreibman, PhD/MD 1 of 77 © 2014 Ken L Schreibman, PhD/MD 2 of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Spine defines our place in the world Spine Clinically Important Central Taxonomy of Life on Earth Central Back pain 2nd most common neurological ailment Structural Structural (headache most common) Flexible Flexible Anatomy Kingdoms: Plants Animals Microbes Anatomy Most common job-related disability Radiographs Radiographs American spend >$50 billion annually on LBP 1.Labeling Phylum: Vertebrates Arthropods 1.Labeling “Nearly everyone at some point has back pain that
2.Body Height 2.Body Height interferes with work, routine daily activities, or recreation” Mammals Insects 3.Alignment Crabs 3.Alignment Half of what MSK does is the spine Spondylo… Birds Spondylo… Reptiles Acute trauma (ER, Clinics, Outside studies) 4.Disc Narrow Amphibians 4.Disc Narrow ACR Approp. ACR Approp. Chronic LBP (Spine Clinic, PCPs) Criteria Criteria Image guided injections for pain www.schreibman.info www.schreibman.info NIH Low Back Pain Fact Sheet © 2014 Ken L Schreibman, PhD/MD 3 of 77 © 2014 Ken L Schreibman, PhD/MD 4 of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Spine has four functions Spine as a structural element Central Structural Central If I were to build a statue, Structural Everything connects to the spine Structural especially one I’d have to Flexible Flexible move across an ocean… Anatomy Protective Anatomy Radiographs Protects spinal cord and nerves Radiographs I’d start with a central 1.Labeling Hemopoietic 1.Labeling spine (2 columns) 2.Body Height 2.Body Height I’d hang a skeletal 3.Alignment Much of the red bone marrow in spine 3.Alignment Vertebral bodies framework from spine Spondylo… Prone to metastases, multiple myeloma Spondylo… Cover with skin
4.Disc Narrow 4.Disc Narrow ACR Approp. Calcium storage ACR Approp. Rigid Central Spine Criteria Osteoporosis spinal fractures Criteria Statue of Liberty Statue of Liberty www.schreibman.info www.schreibman.info © 2014 Ken L Schreibman, PhD/MD 5 of 77 © 2014 Ken L Schreibman, PhD/MD 6 of 77
©Ken L Schreibman, PhD/MD 9/1/14 www.schreibman.info Story of Lumbar Spine: page 2 of 13 1) Variations of Normal
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Spine as a structural element Robots have rigid spines Central If I were to build an Central Structural imaginary robot… Structural Flexible Flexible Anatomy with a head… Anatomy Radiographs and feet… Radiographs 1.Labeling It might require hinged 1.Labeling 2.Body Height arms & legs… 2.Body Height 3.Alignment 3.Alignment Spondylo… With lots of wires… Spondylo…
4.Disc Narrow Rigid central conduit 4.Disc Narrow ACR Approp. via which wires pass ACR Approp. Criteria Criteria www.schreibman.info C3P0 www.schreibman.info YouTube © 2014 Ken L Schreibman, PhD/MD Ep1 7 of 77 © 2014 Ken L Schreibman, PhD/MD 8 of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Spine as Structural Conduit Humans arehave not a flexiblerobots spine Central If I were to build a Central Structural real robot… Structural Flexible Flexible Anatomy iPad for a head Anatomy Radiographs Segway-like wheels Radiographs 1.Labeling Rigid pipe (spine) 1.Labeling 2.Body Height for the wires to pass 2.Body Height 3.Alignment 3.Alignment Spondylo… “Ultimate tool for Spondylo… telecommuting” 4.Disc Narrow 4.Disc Narrow ACR Approp. ACR Approp. Criteria Criteria www.schreibman.info doublerobotics YouTube www.schreibman.info YouTube © 2014 Ken L Schreibman, PhD/MD 9 of 77 © 2014 Ken L Schreibman, PhD/MD 10 of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Spine flexibility from individual vertebrae Trivia: All mammals have 7 cervical vertebrae Central Vertebra: [L] vertere “to turn, bend” Central Somali Amphibians Structural Structural Reticulated have just Same root as versus Giraffe one cervical Flexible Flexible vertebra… Anatomy Literally: “Joints in the spine” Anatomy Radiographs Joints between every vertebrae Radiographs Goliath Frog 1.Labeling 24 (±1) vertebrae between skull/sacrum 1.Labeling 2.Body Height Ribs define the parts of the spine 2.Body Height 3.Alignment 3.Alignment N. American Spondylo… 12 with ribs = Thoracic vertebrae Variable Spondylo… Mastodon 5 below ribs = Lumbar vertebrae number Swans have 4.Disc Narrow 4.Disc Narrow 25 cervical ACR Approp. 7 above ribs = Cervical vertebrae ACR Approp. vertebrae! Criteria Constant number Criteria earthlife.net Wikipedia Mute Swan www.schreibman.info www.schreibman.info Journal of Experimental Zoology 1999; 285:19-26 © 2014 Ken L Schreibman, PhD/MD 11 of 77 © 2014 Ken L Schreibman, PhD/MD 12 of 77
©Ken L Schreibman, PhD/MD 9/1/14 www.schreibman.info Story of Lumbar Spine: page 3 of 13 1) Variations of Normal
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Vertebrae Permit Bending: Right/Left Vertebrae Permit Bending: Back/Front C C Central E Central E R R Structural V Structural V I I Flexible C Flexible C A A Anatomy L Anatomy L T Radiographs H Radiographs O Thoracic spine has 1.Labeling R 1.Labeling Left Right A limited bending Flexion Extension Flexion Extension 2.Body Height C 2.Body Height I 3.Alignment C Ribs 3.Alignment Spondylo… Spondylo… L L U U 4.Disc Narrow M 4.Disc Narrow M B B ACR Approp. A ACR Approp. A Posterior R Side R Criteria View 8° 4° 4° 8° Criteria View 12° 8° 4° 4° 8°12° www.schreibman.info The Western Journal of paulmanley.co.uk www.schreibman.info The Western Journal of paulmanley.co.uk © 2014 Ken L Schreibman, PhD/MD Emergency Medicine 13 of 77 © 2014 Ken L Schreibman, PhD/MD Emergency Medicine 14 of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Vertebral Flexion/Extension Not Uniform Spine is Straight (from the back) C Central E Central Most of the spine’s ROM R Vertical line all vertebrae Structural V Structural Lower Cervical spine I Flexible C Flexible Scoliosis: Curved spine A C5-C6* L Anatomy Anatomy Right curve: “Dextroscoliosis” Radiographs *Where DDD Occurs Radiographs [L] dexter: “dexterity” 1.Labeling 1.Labeling Dextro Flexion Extension Left curve: “Levoscoliosis” 2.Body Height 2.Body Height [L] laevus: “lame, weak” 3.Alignment 3.Alignment Note: By convention, This patient has Spondylo… Spondylo… Levo L scoliosis radiographs Dextroscoliosis of U are displayed like the T-spine… 4.DiscNarrow M 4.DiscNarrow B we’re looking at the and Levoscoliosis ACR Approp. Lower Lumbar spine A ACR Approp. R patient from the back of the L-spine Criteria L4-L5* 12° 8° 4° 4° 8°12° Criteria M,B 13yoF www.schreibman.info Yudaev-Racei Yuri paulmanley.co.uk www.schreibman.info K,K 14yoF © 2014 Ken L Schreibman, PhD/MD 15 of 77 © 2014 Ken L Schreibman, PhD/MD 16 of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Spine is NOT Straight (from the side) Lumbar Vertebrae Central Central T12 5 Lumbar Vertebrae (usually) Structural Lordosis C-spine: Normal forward curve Structural Flexible Flexible TP L1 TP Named: L1-L5 Anatomy “Cervical Lordosis” Anatomy Don’t have ribs (usually) TP L2 TP Radiographs Kyphosis T-spine: Normal back curve Radiographs Thoracic vertebrae have ribs TP 1.Labeling “Thoracic Kyphosis” 1.Labeling TP L3 Lowest is T12 (usually) 2.Body Height 2.Body Height Have Transverse Processes 3.Alignment L-spine: Normal forward curve 3.Alignment TP L4 TP Spondylo… Spondylo… Lowest Lumbar (L5 usually) Lordosis “Lumbar Lordosis” TP TP 4.Disc Narrow 4.Disc Narrow L5 Articulates with Sacrum ACR Approp. ACR Approp. S1 Criteria Criteria S1 www.schreibman.info B,J 15yoM www.schreibman.info Anterior View © 2014 Ken L Schreibman, PhD/MD 17 of 77 © 2014 Ken L Schreibman, PhD/MD 18 of 77
©Ken L Schreibman, PhD/MD 9/1/14 www.schreibman.info Story of Lumbar Spine: page 4 of 13 1) Variations of Normal
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal 2 Lumbar Articulations Parts of Vertebra: Processes Central Discs T12T12 Central Side View Top (Axial) View Disc Structural Facet Facet Structural Flexible Between L1L1 Flexible Posterior Disc Vertebral Anatomy “vertebral Facet Facet Anatomy Elements Vertebral bodies” L2L2 TP Radiographs Disc Radiographs Body Body Facet Facet 1.Labeling Facets L3L3 1.Labeling Body: Primary L3 Facet 2.Body Height Between Disc Disc Facet 2.Body Height structural 3.Alignment L4 3.Alignment component “posterior L4 Facet Facet Spine: [Old French] Spondylo… Disc Spondylo… espine “Thorn-like” elements” Facet 4.Disc Narrow L5 4.Disc Narrow Posterior ACR Approp. Disc ACR Approp. SP Elements Criteria S1 Criteria www.schreibman.info AnteriorSide View View Oblique Post www.schreibman.info Spinosaurus © 2014 Ken L Schreibman, PhD/MD 19 of 77 © 2014 Ken L Schreibman, PhD/MD 20 of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Parts of Vertebra: Facets Parts of Vertebra: Canal Central Superior articular process Central Side View Top (Axial) View Side View Top (Axial) View Structural Structural Flexible Vertebral Posterior Flexible Vertebral Posterior Anatomy Elements Vertebral Anatomy Elements Vertebral Radiographs Body Pars Body Radiographs Body Body Inter- 1.Labeling articularis 1.Labeling P P Inferior Pedicle Canal 2.Body Height articular 2.Body Height process 3.Alignment Superior 3.Alignment articular Pedicles: Connect posterior Spondylo… process Spondylo… elements to vertebral body Lamina 4.Disc Narrow Posterior 4.Disc Narrow Posterior Body + Pedicles + Lamina = Bony Canal ACR Approp. Facets: Elements ACR Approp. Elements Criteria Sliding joints Criteria Bony Canal: Protects spinal cord/nerves www.schreibman.infovisuallymedical.com www.schreibman.info © 2014 Ken L Schreibman, PhD/MD 21 of 77 © 2014 Ken L Schreibman, PhD/MD 22 of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Parts of Vertebra: Neural Foramen Spinal Nerves Central Side View Top (Axial) View Central Spinal nerves exit neural Structural Structural Neural Foramen: Lumbar Nerves: foramen at every level Flexible Keyhole-shaped opening Travel thru canal Flexible Anatomy Under pedicle Exit at NF Anatomy Nerves named relative to bodies under pedicles Radiographs Front of facet Radiographs Lumbar/Thoracic nerves named Behind Disc 1.Labeling NF 1.Labeling for pedicle they pass under Disc Canal
2.Body Height 2.Body Height L3 nerve passes under L3 pedicle 3.Alignment 3.Alignment via the L3-L4 neural foramen Spondylo… Spondylo… Cervical nerves named L4
4.Disc Narrow 4.Disc Narrow for pedicle they pass over ACR Approp. ACR Approp. L3 C7 nerve passes over C7 pedicle Criteria Criteria Nerve via the C6-C7 neural foramen (why?) www.schreibman.info www.schreibman.info »8 Cervical Nerves © 2014 Ken L Schreibman, PhD/MD 23 of 77 © 2014 Ken L Schreibman, PhD/MD 24 of 77
©Ken L Schreibman, PhD/MD 9/1/14 www.schreibman.info Story of Lumbar Spine: page 5 of 13 1) Variations of Normal
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal MRI Well Shows Spinal Nerves MRI Well Shows Spinal Nerves Central Sagittal T1 T2 Fat Suppressed Central T2 Fat Suppressed Axial (parallel to discs) Structural Fat=bright Spinal Fat=dark Spinal Structural Fluid=bright Spinal
T2 Fluid=bright Fat=bright Flexible Midline Fluid=dark Cord Fluid=bright Cord Flexible Cord Body Anatomy Conus Anatomy Pedicle CSF Medullaris Pedicle Radiographs Radiographs T2 1.Labeling 1.Labeling Body Exiting Cauda Cauda Nerves Cauda 2.BodyHeight Axial Reference 2.BodyHeight Sub Q NF Image Equina Equina Fat Equina NF 3.Alignment Lumbar 3.Alignment Lumbar Conus Medullaris L4 L4 L4
Nerves Nerves Spondylo… End of Cord (~L1) SubQ SubQ Spondylo… SubQ Lamina Lamina Fat Fat Fat 4.Disc Narrow Cauda Equina CSF CSF 4.Disc Narrow CSF Spinous ACR Approp. “Horse’s tail” ACR Approp. Process Criteria Nerves below conus Criteria Sagittal Reference Image www.schreibman.info R,R 29yoF www.schreibman.info R,R 29yoF © 2014 Ken L Schreibman, PhD/MD 25 of 77 © 2014 Ken L Schreibman, PhD/MD 26 of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal MRI Well Shows Bones MRI Well Shows Bone Marrow Central Central Sagittal T1:Thru NF T1: Midline Can tell new T12 T1 T12 T2+FST12 Structural Fat=bright Fat=bright Structural Fx Thru NF Fxs from old L1 Flexible Flexible L1 L1 Anatomy Anatomy T1: Fat=Hi L2 Bodies L2 L2 Radiographs Radiographs Dark signal: Fx 1.Labeling 1.Labeling L3 L3 Axial Reference Non-fatty Fx L3 2.Body Height Image 2.Body Height 3.Alignment 3.Alignment L4 L4 L4 L4 L4 SP T2+Fat Sat: Fx Spondylo… NF Spondylo… Fluid=Hi L5 L5 L5 4.Disc Narrow Pedicle 4.Disc Narrow Hi signal: ACR Approp. Exiting ACR Approp. S1 S1 S1 Edema Criteria L4 Nerve Criteria L1 & L5 recent & active fractures www.schreibman.info R,R 29yoF www.schreibman.info F,R 77yoM © 2014 Ken L Schreibman, PhD/MD 27 of 77 © 2014 Ken L Schreibman, PhD/MD L2 & L3 old & quiescent 28fractures of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal MRI Well Shows Bone Marrow Central T2+FatSup Not all high signal Central Structural Mid-Sagittal Structural We’re Flexible on T2 is abnormal Flexible Anatomy Normal Anatomy Radiographs Lumbar Radiographs of Ourselves 1.Labeling Venous 1.Labeling
2.Body Height Plexus 2.Body Height 3.Alignment Common 3.Alignment Spondylo… on mid- Spondylo… sagittal 4.Disc Narrow 4.Disc Narrow Prominent ACR Approp. in young ACR Approp. Criteria Criteria www.schreibman.info R,R 29yoF www.schreibman.info hiartmagazine.com © 2014 Ken L Schreibman, PhD/MD 29 of 77 © 2014 Ken L Schreibman, PhD/MD 30 of 77
©Ken L Schreibman, PhD/MD 9/1/14 www.schreibman.info Story of Lumbar Spine: page 6 of 13 1) Variations of Normal
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal WOW: Imaging Low Back Pain Radiographs: AP View Central 0) History & Physical Central Shot standing T12 AP view super- Structural Structural imposes front Conservative management (ACR: 6 weeks) on back Flexible Flexible L1 Anatomy 1) Radiographs (AP & Lateral) Anatomy L2 Radiographs Best to show the big picture Radiographs 1.Labeling 2) MRI (without contrast) 1.Labeling X-ray L3
2.Body Height Well shows discs, nerves, bones 2.Body Height tube 3.Alignment 3) Refer to Spine Clinic 3.Alignment L4 Spondylo… Spondylo… Should include: CT: Ordered by ER & Spine Clinic T12 (ribs) L5 4.Disc Narrow 4.Disc Narrow (Bone scan, SPECT, PET/CT) L1-L5 ACR Approp. Nuclear Medicine ACR Approp. S1 Criteria Ordered by specialty clinics Criteria S1 (top of sacrum) www.schreibman.info www.schreibman.info Marty 11½ © 2014 Ken L Schreibman, PhD/MD 31 of 77 © 2014 Ken L Schreibman, PhD/MD 32 of 77
Story of the LumbarFacets Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Radiographs: AP View Radiographs: Lateral View Central AP view super- Central Shot standing Structural imposes front Structural Flexible on back Flexible Anatomy Vertebral Body Anatomy Radiographs Difficult to Radiographs 1.Labeling Ped S P Ped assess Disc 1.Labeling X-ray p r spaces 2.Body Height 2.Body Height tube i o 3.AlignmentTransverse n c Transverse 3.Alignment Spondylo…Processes o e Processes Spondylo… Should include: u s T12 (ribs) 4.Disc Narrow s s 4.Disc Narrow We can still L1-L5 ACR Approp. Facets see lots of ACR Approp. Criteria anatomy Criteria S1 (top of sacrum) www.schreibman.info V,S 18yoF www.schreibman.info Marty 11½ © 2014 Ken L Schreibman, PhD/MD 33 of 77 © 2014 Ken L Schreibman, PhD/MD 34 of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Radiographs: Lateral View($Money View) How I Look at L-Spine Radiographs Central Shows the Big Picture Central AP & Lateral side- AP Lateral Structural Well shows vertebral alignment Structural Flexible Flexible by-side on PACS T12 T12 Normal Lordosis, smooth curve Anatomy Anatomy 1. Label the vertebrae! L1 L1 vs spondylolisthesis Radiographs Radiographs Iliac Crests @ L4-L5 Well shows vertebral body height L2 L2 1.Labeling 1.Labeling UW MSK Policy: Parallel superior/inferior end plates L3 L3 2.Body Height Slight wedging at T-L junction is common 2.Body Height All Lumbar spines 3.Alignment 3.Alignment L4 Shows Disc space widths get labeled on PACS L4 Spondylo… Spondylo… L5 Wider @ Lower Levels Why the big fuss? L5
4.Disc Narrow 4.Disc Narrow L5-S1 variable S1 ACR Approp. L4-L5 widest ACR Approp. Sometimes it’s hard to S1 Criteria DDD starts L4-L5 K,D 44yoM Criteria count… J,D 20yoM www.schreibman.info www.schreibman.info © 2014 Ken L Schreibman, PhD/MD 35 of 77 © 2014 Ken L Schreibman, PhD/MD 36 of 77
©Ken L Schreibman, PhD/MD 9/1/14 www.schreibman.info Story of Lumbar Spine: page 7 of 13 1) Variations of Normal
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Sometimes it’s hard to count… Sometimes it’s hard to count… Central How many LEGS Central How many FEET Structural Structural Flexible does this Flexible does this Anatomy elephant Anatomy elephant Radiographs Radiographs 1.Labeling have? 1.Labeling have?
2.Body Height 2.Body Height 3.Alignment 3.Alignment Spondylo… Spondylo…
4.Disc Narrow 4.Disc Narrow ACR Approp. ACR Approp. Criteria Criteria www.schreibman.info Roger Shepard www.schreibman.info Roger Shepard © 2014 Ken L Schreibman, PhD/MD 37 of 77 © 2014 Ken L Schreibman, PhD/MD 38 of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Sometimes it’s hard to count… Transitional Vertebrae: Hypoplastic 12th Ribs Central Central T12 lowest th How many shelves are here? lowest rib? 12 rib is the smallest Structural Structural rib T12 L1 Sometimes very small T12 Flexible Flexible L1 L2 TP? Hypoplastic Anatomy Anatomy Sometimes absent L1 Radiographs Radiographs L2 L3 Unilateral or Bilateral L2 1.Labeling 1.Labeling L3 L3 L4 Iliac 2.Body Height 2.Body Height Crests Iliac @L4-5 L4 3.Alignment 3.Alignment Crests L4 L5 Spondylo… Spondylo… @L4-5 L5 L5 L6? T12 4.Disc Narrow 4.Disc Narrow S1 ACR Approp. ACR Approp. S1 S1 For more PowerPoint enhanced illusions, see my Hypoplastic Criteria lecture “Pitfalls of the Human Visual System” Criteria th www.schreibman.info Oscar Reutersvärd www.schreibman.info M,S 22yoF 12 ribs J,T 33yoF © 2014 Ken L Schreibman, PhD/MD 39 of 77 © 2014 Ken L Schreibman, PhD/MD 40 of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Transitional Vertebrae: Hypoplastic 12th Ribs Transitional Vertebrae: Lumbar Ribs Central AP Lateral Central AP Lateral T12T11 Very hypoplastic Lumbar ribs Structural T11 Structural 12th ribs makes it rib rib makes it look Flexible L1T12 T12 Flexible T12 L1 L1 like there are Anatomy L2 L1 look like there are Anatomy L1 L1 L2 4 lumbar vert. Radiographs 6 lumbar vertebrae Radiographs L2 L3 L2 L2 Non-rib-bearing 1.Labeling Non-rib-bearing vertebrae 1.Labeling L2 L3 L3 L4 L3 vertebrae 2.Body Height L3 2.Body Height Iliac Lumbar ribs are 3.Alignment Sometimes it’s hard 3.Alignment Crests L3 L4 L4 L5 L4 L4 @L4-5 not uncommon Spondylo… to count… Spondylo… L4 L5 49/559 (9%) L6? L5 L5 L5 4.Disc Narrow 4.Disc Narrow skeletons Wash U S1 S1 S1 ACR Approp. S1 S1 Schreibman’s Rule: ACR Approp. S1 1944 Lanier: Am J Phys Criteria Iliac Crests @ L4-L5 Criteria Anthropol 2:137-146 www.schreibman.info Z,C 30yoF www.schreibman.info B,J 56yoF © 2014 Ken L Schreibman, PhD/MD 41 of 77 © 2014 Ken L Schreibman, PhD/MD 42 of 77
©Ken L Schreibman, PhD/MD 9/1/14 www.schreibman.info Story of Lumbar Spine: page 8 of 13 1) Variations of Normal
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Not Everyone Has 12 Ribs Transitional Vertebrae: Sacralization of L5 Central Not Central AP Lateral everyone T12 T12 Fairly common Structural has 10 Structural fingers L1 ~14% Flexible T8 Flexible L1 Anatomy Anatomy 1989: 46/340 sacra L2 L2 (Arab and Indian) Radiographs T11 Radiographs T12 1.Labeling 1.Labeling L3 L3 18% T13 1936: Australian 2.Body Height L1 2.Body Height Fx of… L4 L4 aboriginals 3.Alignment This L2 3.Alignment patient …13 Spondylo… L3 thoracic Spondylo… L5? L5 6% 12 Fingers has 13 vertebrae 4.Disc Narrow ribs… L4 4.Disc Narrow S1? 1927: Japanese ACR Approp. L5 ACR Approp. L5 is fused to S1! No disc between Can be Criteria S1 This patient has Criteria L5 & S1 bilateral... www.schreibman.info only 10 ribs! www.schreibman.info H,S 20yoF anatomyatlases.org © 2014 Ken L Schreibman, PhD/MD B,H 13yoF M,A 4313yoM of 77 © 2014 Ken L Schreibman, PhD/MD 44 of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Transitional Vertebrae: Sacralization of L5 Transitional Vertebrae: Sacralization of L5 Central Can be Central Can be Structural unilateral Structural fused Flexible Can be Flexible “Complete Anatomy L5 is sacralized Anatomy sacralization” (fused) to S1 …but not on L5 Radiographs fused Radiographs on the right… the left “Complete Can be 1.Labeling sacralization” 1.Labeling an extra L5 Complete S1 Partial 2.Body Height 2.Body Height sacralization of sacralization of facet 3.Alignment 3.Alignment L5 on the right L5 on the left between Spondylo… S1 Spondylo… L5-S1 4.Disc Narrow 4.Disc Narrow “Partial ACR Approp. ACR Approp. sacralization” Criteria Criteria www.schreibman.info S,L 43yoF www.schreibman.info C,D 28yoM © 2014 Ken L Schreibman, PhD/MD 45 of 77 © 2014 Ken L Schreibman, PhD/MD 46 of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Transitional Vertebrae are Common Final comments on labeling for Radiologists Central Lumbar ribs (L1) Central UW MSK Policy Structural Structural T12 9% of population ALL LUMBAR VERTEBRAE Flexible Flexible L1 Anatomy Sacralization of L5 Anatomy GET LABELED L2 Radiographs ~14% of population (6-18%) Radiographs All: Radiographs/CTs/MRs L1 1.Labeling Hypoplastic 12th ribs 1.Labeling Easy to do on PACS L3 2.Body Height 2.Body Height Single view or entire stack 3.Alignment I can’t find a number for this, but I’m guessing it’s at 3.Alignment Lytic pedicleL4 Spondylo… least as common as sacralized L5 Spondylo… As easy on AP as Lateral Expansile ScoliosisL5 4.Disc Narrow Some patients have both 4.Disc Narrow Forces me to look at each ACR Approp. ACR Approp. Pedicle, Spinous Process Hx: PainS1 Criteria 30-40% of population have Trans. Vert. Criteria Osteoblastoma www.schreibman.info www.schreibman.info © 2014 Ken L Schreibman, PhD/MD 47 of 77 © 2014 Ken L Schreibman, PhD/MD 48 of 77
©Ken L Schreibman, PhD/MD 9/1/14 www.schreibman.info Story of Lumbar Spine: page 9 of 13 1) Variations of Normal
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal How I Look at L-Spine Radiographs Lumbar vs Thoracic Radiographs Central AP & Lateral side- AP Lateral Central L-spine Fx Lumbar Radiographs T-spine Structural Structural T12 T1 Cover entire L-spine T2 by-side on PACS T12 T12 Flexible Flexible L1 From T12 – S1 T3 Anatomy 1. Label the vertebrae! L1 L1 Anatomy Centered on L3 T4 Radiographs Comment on Trans. Vert. Radiographs L2 T5 L2 L2 1.Labeling 2. Vertebral body height 1.Labeling Thoracic Radiographs T6 L3 T7 L3 L3 Cover entire T-spine 2.Body Height Parallel end plates 2.Body Height T8 3.Alignment Pathologic fractures can L4 3.Alignment From T1 – T12 L4 L4 Usually can’t see T1 T9 Spondylo… occur at any level L5 Spondylo… T10 L5 Centered on T7
Due to osteoporosis, tumor 4.DiscNarrow 4.DiscNarrow L5 T11 S1 S1 But neither optimally ACR Approp. Traumatic fractures tend ACR Approp. T12 S1 Criteria to occur at T-L junction J,D 20yoM Criteria shows T-L junction www.schreibman.info www.schreibman.info V,V 40yoM © 2014 Ken L Schreibman, PhD/MD 49 of 77 © 2014 Ken L Schreibman, PhD/MD 50 of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Thoraco-Lumbar Radiographs Assessing Fracture Stability Fx Central L-spine TL-junctionT7 Thoraco- T-spine Central Radiologists: TL-junction Structural T12 T1 Structural Measure wedging T8 Lumbar T2 Flexible Flexible L1 T9 Centered at T3 Easy on PACS T4 Anatomy T10 T-L junction Anatomy Don’t measure Radiographs L2 T5 Radiographs height loss T11 Good for T11 25º 29º 1.Labeling T6 1.Labeling 20º L3 T12 seeing T7 Measure focal T12
2.Body Height 2.Body Height kyphosis L1 fractures at T8 L1 3.Alignment L4 T-L junction T9 3.Alignment Cobb L2 Superior end Spondylo… Notice how much T10 Spondylo… plate level above 4.Disc Narrow L3 4.Disc Narrow L5 easier it is to see T11 Inferior end ACR Approp. L4 the T12 wedging T12 ACR Approp. plate level below @ 2 weeks @ 3 months @ 6 months Criteria S1 Criteria (upright in brace) www.schreibman.info V,V 40yoM www.schreibman.info V,V 40yoM © 2014 Ken L Schreibman, PhD/MD 51 of 77 © 2014 Ken L Schreibman, PhD/MD 52 of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Congenital/Physiologic Wedging Congenital Wedging vs Fracture Central Vertebral bodies = basically square Central Congenital wedging Structural Structural Parallel Superior / Inferior end plates Keystone shaped Flexible T12 T-L Junction is a Transition Zone Flexible Anatomy Anatomy Traumatic wedging L1 Lumbar Lordosis / Thoracic Kyphosis Radiographs L1 (or T12 or T11) can be keystone shaped Radiographs Right Trapezoid 1.Labeling L2 1.Labeling L3 2.Body Height 2.Body Height Depressed Superior end 3.Alignment L4 3.Alignment Superior & Inferior plate only Spondylo… L1 Spondylo… end plates wedged L5 by the same amount
4.Disc Narrow 4.Disc Narrow S1 Superior & Inferior end ACR Approp. plates slightly wedged, ACR Approp. Criteria by the same amount Criteria History Helps: Acute onset, recent trauma www.schreibman.info C,K 41yoM www.schreibman.info C,K 41yoM Comparison with old images helps A LOT V,V 40yoM © 2014 Ken L Schreibman, PhD/MD wikipedia.org 53 of 77 © 2014 Ken L Schreibman, PhD/MD May need CT/MRI to determine if acute 54 of 77
©Ken L Schreibman, PhD/MD 9/1/14 www.schreibman.info Story of Lumbar Spine: page 10 of 13 1) Variations of Normal
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal How I Look at L-Spine Radiographs Lumbar vs Scoliosis Radiographs Central AP & Lateral side- AP Lateral Central Modern CR X-rays use phosphor Structural Structural plates held in cassettes by-side on PACS T12 Flexible T12 Flexible Largest plates are 14x17” Anatomy 1. Label the vertebrae! L1 L1 Anatomy From the old film days Radiographs Radiographs 2. Vertebral body height L2 L2 1.Labeling 3. Alignment 1.Labeling Scoliosis cassette hold 2 plates L3 L3 2.Body Height Lateral: Normal Lordosis 2.Body Height Two plates w/one x-ray exposure L4 3.Alignment vs Spondylolisthesis L4 3.Alignment 14x17 Upper + Lower plates stitched Spondylo… AP: Straight L5 Spondylo… L5 together, automatically 14x33 4.Disc Narrow vs Scoliosis 4.Disc Narrow S1 Fiducial marks 1-inch overlap ACR Approp. Scoliosis should be imaged S1 ACR Approp. Yield an image up to 14x33” Criteria with “Scoliosis” Radiographs J,D 20yoM Criteria www.schreibman.info www.schreibman.info Marty 17 © 2014 Ken L Schreibman, PhD/MD 55 of 77 © 2014 Ken L Schreibman, PhD/MD 56 of 77
Story of the Lumbar Spine:1 VariationsShot standing of Normal Story of the Lumbar Spine:1 Variations of Normal By convention, scoliosis PA views Scoliosis Radiographs are displayed like we’re looking at Normal Lumbar Lordosis Central PA view – Upper Half the patient from the back Central Smooth Curves Structural Structural Stitched Together Along back vertebral bodies Flexible Fiducial marks Flexible Anatomy Anatomy PLLL “Posterior Longitudinal Ligament Line” Radiographs Radiographs (Fronts tend to have osteophytes) 1.Labeling 1.Labeling Along back spinous process “Spinous Process Line” 2.Body Height 2.Body Height O-phyte 3.Alignment 3.Alignment SPL Continuous Curves Spondylo… Spondylo… Fiducial marks 4.Disc Narrow 4.Disc Narrow ACR Approp. ACR Approp. Criteria PA view– Lower Half Criteria www.schreibman.info B,J 15yoM www.schreibman.info K,D 44yoM © 2014 Ken L Schreibman, PhD/MD 57 of 77 © 2014 Ken L Schreibman, PhD/MD 58 of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Spondylolisthesis Spondylolysis Central [Gr] spondylo: “vertebrae” Central [Gr] spondylo: “vertebrae” Structural Structural Flexible oliothesis: “slipping” Flexible lysis: “dissolution” Anatomy Anterior slippage of a vertebra Anatomy Pars Interarticularis Defect Radiographs PLLL relative to the one below it Radiographs PLLL disrupted aka “Anterolisthesis” @ L5-S1 1.Labeling L3 1.Labeling 2.Body Height 3 causes of spondylolisthesis 2.Body Height SPL disrupted L4 Pars Intact 3.Alignment 1.DDD (most common) 3.Alignment L4 SPL @ L4-L5 Spondylo… Spondylo… L5 Spinous SPL PLLL & SPL disrupted at same level SP 4.Disc Narrow 4.Disc Narrow Process not 2.Spondylolysis PLLL ACR Approp. Anterolisthesis ACR Approp. attached to Pars Defect 3. Trauma (least common) Anterolisthesis Criteria L4 on L5 Criteria L5 on S1 L5 Body www.schreibman.info G,M 68yoF etymonline.com www.schreibman.info E,B 27yoF oed.com © 2014 Ken L Schreibman, PhD/MD 59 of 77 © 2014 Ken L Schreibman, PhD/MD 60 of 77
©Ken L Schreibman, PhD/MD 9/1/14 www.schreibman.info Story of Lumbar Spine: page 11 of 13 1) Variations of Normal
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Spondylolysis: Prevalence Spondylolysis: CT Gold Standard Central Central Lateral Sagittal CT Sagittal CT Sagittal CT Japan: 2,000 CTs (20-92yo) not for back pain RIGHT LEFT LEFT Structural 6% Spondylolysis (M:F = 2:1) Structural Flexible Flexible 6 months later… 80% Bilateral Intact Dx: Unilateral spondylolysis Anatomy 75% of these had spondylolisthesis Anatomy without spondylolisthesis Radiographs 20% Unilateral Radiographs 1.Labeling 8% of these had spondylolisthesis Intact 1.Labeling L3
2.Body Height 2.Body Height 90% @ L5 Pars Pars 3.Alignment Probably a stress fracture 3.Alignment Intact Intact NEW Spondylo… Spondylo… Pars Due to vertical sheer 4.Disc Narrow 4.Disc Narrow Pars Pars Defect ACR Approp. Vertical sheer greatest at Vertical ACR Approp. Defect Intact Defect Criteria L5 pars interarticularis Criteria Negative www.schreibman.info Spine 2009 Oct 1;34(21):2346-50 M,J 35yoM www.schreibman.info O,C 13yoM © 2014 Ken L Schreibman, PhD/MD 61 of 77 © 2014 Ken L Schreibman, PhD/MD 62 of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Spondylolysis: Lateral View Spondylolysis: Oblique Views Central May be able to see on lateral view if there is enough Central Shot laying on X-ray table Structural spondylolisthesis to separate body from spinous process Structural Unlike standing AP & Lateral Flexible Flexible X-ray Oblique See scotty dog Anatomy Anatomy tube Superior Superior Radiographs Radiographs Articular TP Articular L4 Process Process 1.Labeling 1.Labeling Pedicle Pedicle 2.Body Height 2.Body Height SP Trans. 3.Alignment 3.Alignment Wedge Process Pars Inter- Spondylo… Pars Spondylo… articularis Inferior Pars Inter- 4.Disc Narrow 4.Disc Narrow Defect Articular articularis ACR Approp. ACR Approp. Process Inferior Anterolisthesis Articular Criteria L5 on S1 Criteria Process www.schreibman.info C,D 47yoF R,C 21yoF www.schreibman.info B,D 27yoM © 2014 Ken L Schreibman, PhD/MD 63 of 77 © 2014 Ken L Schreibman, PhD/MD 64 of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Spondylolysis: Oblique Views Radiographs Show the Big Picture Central Oblique view Other Oblique Central For Alignment: Get Standing Views Structural Structural Pars For alignment of entire Lumbar spine: Flexible Pars Intact Flexible Anatomy Intact Anatomy Get Lumbar spine radiographs Radiographs Radiographs For alignment of entire Thoracic spine: Pars Pars 1.Labeling Defect Defect 1.Labeling Get Thoracic spine radiographs
2.Body Height 2.Body Height For alignment of Thoraco-Lumbar Junction 3.Alignment 3.Alignment Get Thoraco-Lumbar radiographs Spondylo… Spondylo… For alignment of ENTIRE SPINE (C+T+L)
4.Disc Narrow 4.Disc Narrow Get Scoliosis radiographs ACR Approp. ACR Approp. Criteria Criteria For Stability: Get Flexion/Extension www.schreibman.info M,J 20yoM www.schreibman.info © 2014 Ken L Schreibman, PhD/MD 65 of 77 © 2014 Ken L Schreibman, PhD/MD 66 of 77
©Ken L Schreibman, PhD/MD 9/1/14 www.schreibman.info Story of Lumbar Spine: page 12 of 13 1) Variations of Normal
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Flexion/Extension Views Flexion/Extension: Good ROM Central Flexion Extension Central Neutral Lateral Structural Structural Most Flexible Flexible people flex Anatomy Anatomy from hips Radiographs Radiographs 1.Labeling 1.Labeling
2.Body Height 2.Body Height 3.Alignment 3.Alignment Spondylo… Spondylo…
4.Disc Narrow 4.Disc Narrow ACR Approp. ACR Approp. Notice Criteria Criteria Sacrum www.schreibman.info Marty 17 www.schreibman.info S,A 63yoF © 2014 Ken L Schreibman, PhD/MD I find these of limited value 67 of 77 © 2014 Ken L Schreibman, PhD/MD Orientation 68 of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal Flexion/Extension: Limited ROM Flexion/Extension: Spondylolysis Central Central Neutral Lateral Extension Flexion Structural Structural Flexible Flexible L2 L2 L2 Pars Anatomy Anatomy Defect Radiographs Radiographs L3 L3 1.Labeling 1.Labeling L3
2.Body Height 2.Body Height L4 L4 3.Alignment 3.Alignment L4 Spondylo… Spondylo… L5 L5 L5 4.Disc Narrow 4.Disc Narrow ACR Approp. ACR Approp. S1 S1 S1 Criteria Criteria www.schreibman.info B,B 70yoF www.schreibman.info M,K 33yoM Only 3% Pars defects @ L3 © 2014 Ken L Schreibman, PhD/MD 69 of 77 © 2014 Ken L Schreibman, PhD/MD Spine 2009 Oct 1;34(21):2346-50 70 of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal How I Look at L-Spine Radiographs DDD: My Grading System Central AP Lateral Central If I have to Lateral$ PACST12 AP AP & Lateral side- convince the Measurements T12 Structural Structural L1 Flexible by-side on PACS T12 T12 Flexible resident the disc L1 is narrow Anatomy 1. Label the vertebrae! L1 L1 Anatomy L2-3 > L1-2 =MILDLY L2 L2 Radiographs Radiographs 2. Vertebral body height L2 L2 NARROWED 1.Labeling 1.Labeling If we agree it’s L3-4 < L2-3L3 L3 3. Alignment L3 L3 Mild? 2.Body Height 4. Disc Spaces 2.Body Height narrow 3.Alignment L4 3.Alignment =MODERATELY L4-5 < L3-4L4 L4 Wider @ Lower Levels L4 NARROWED Spondylo… L5-S1 variable L5 Spondylo… L5 L5 Vacuum L5 4.Disc Narrow 4.Disc Narrow phenomenon L4-L5 widest S1 S1 L5-S1 >> S1 ACR Approp. ACR Approp. S1 DDD starts L4-L5 =SEVERLY Can’t assess disc Criteria J,D 20yoM Criteria NARROWED width on AP www.schreibman.info www.schreibman.info W,L 48yoF © 2014 Ken L Schreibman, PhD/MD 71 of 77 © 2014 Ken L Schreibman, PhD/MD 72 of 77
©Ken L Schreibman, PhD/MD 9/1/14 www.schreibman.info Story of Lumbar Spine: page 13 of 13 1) Variations of Normal
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal ACR Appropriateness Criteria ACR Appropriateness Criteria Central Date of origin: 1996 Central Last review date: 2011 Acute uncomplicated LBP without red flags is a benign, Structural Structural self-limited condition that does not require imaging eval. Flexible American College of Radiology Flexible ACR Appropriateness Criteria® 1. Trauma (cumulative) 7. IV drug use Anatomy Anatomy 2. Unexpected wt. loss 8. Prolonged steroid use Radiographs Low Back Pain Radiographs 12 (Page 7) 3. Osteoporosis (♀>50y) 9. Age > 70 years 1.Labeling 1.Labeling 4. Fever, Infection (UTI) 10.Focal Neuro (cauda equina) 2.Body Height 2.Body Height 3 5. Diabetes 11.Duration > 6 weeks 3.Alignment 3.Alignment 6. Cancer, Immunosuppression 12.Prior surgery Spondylo… Spondylo… Radiographs may be useful in any of these categories. 4.Disc Narrow 4.Disc Narrow ACR Approp. ACR Approp. May be sufficient for the initial evaluation: 1, 3, 9 Criteria Criteria www.schreibman.info American College of Radiology Appropriateness Criteria 2011 www.schreibman.info American College of Radiology Appropriateness Criteria 2011 © 2014 Ken L Schreibman, PhD/MD 73 of 77 © 2014 Ken L Schreibman, PhD/MD 74 of 77
Story of the Lumbar Spine:1 Variations of Normal Story of the Lumbar Spine:1 Variations of Normal ACR Appropriateness Criteria What to Order When (WOW) Central MR has displaced CT and myelography as the initial Central Low back pain < 6 weeks, no red flags Structural imaging modality of choice in complicated LBP. Structural No imaging Flexible With contrast: neoplasia, infection, post-operative evaluation. Flexible Conservative treatment, Physical Therapy Anatomy Anatomy LBP with red flags, including > 6 weeks Radiographs CT is useful in patients with surgical fusion, bone Radiographs structural abnormalities, MRI contraindications. Get Radiographs today in clinic 1.Labeling 1.Labeling Schedule MRI
2.Body Height Other modalities are used in selected patients for 2.Body Height Without IV Contrast (if no prior lumbar surgery) 3.Alignment problem solving but not routine clinical practice. 3.Alignment Consider referral to Spine/Sports Clinic Spondylo… Nonspecific lumbar disc abnormalities are common in Spondylo… Patients with fusions throughout spine (AS, DISH) 4.Disc Narrow asymptomatic patients, readily demonstrated on MR. 4.Disc Narrow ACR Approp. ACR Approp. who have pain after even minor trauma MUST get Criteria Don’t treat the images; treat the patient. Criteria spine CT urgently for non-displaced fractures! www.schreibman.info American College of Radiology Appropriateness Criteria 2011 www.schreibman.info © 2014 Ken L Schreibman, PhD/MD 75 of 77 © 2014 Ken L Schreibman, PhD/MD 76 of 77
Story of the Lumbar Spine:1 Variations of Normal Any Questions? Central Structural Flexible Anatomy Radiographs 1.Labeling
2.Body Height 3.Alignment Spondylo…
4.Disc Narrow ACR Approp. Criteria www.schreibman.info pinterest.com © 2014 Ken L Schreibman, PhD/MD 77 of 77
©Ken L Schreibman, PhD/MD 9/1/14 www.schreibman.info