Radiologic Evaluation of Musculoskeletal Dİsorders

1. Radiologic Evaluation of Musculoskeletal Dİsorders Assoc. Prof. Dr. Ercan MADENCI Istanbul Medeniyet University Medical School Department of PMR

2. Keys to Success in Radiology • Know what to order • Know what a complete optimal imaging series is and don’t accept less • Read by check list • Know the common lesions • Know the commonly MISSED lesions

3. The Musculoskeletal System • Bones • Joints • Muscles • Ligaments • Tendons • Soft tissues

4. The Spine Cervical Thoracic Lumbar-sacral

5. Plain Film Check List • BONES • JOINTS • SOFT TISSUES: the ligaments, tendons, muscles, skin and subcutaneous tissues all blend together to give one uniform density

6. Plain Films • The most common imaging modality • Definitive for many conditions • A good screen for many others

7. Plain film: Cervical • The LATERAL provides most of the information • Look for malalignment, fractures, distraction, destruction, degenerative changes

8. Plain Film: Thoracic and Lumbar • Same check list as for cervical spine

9. Cervical Spine AP view

10. Cervical Spine lateral view

11. Cervical spine oblique view

12. Lumbar spine ap view

13. Lumbar spine-lateral view

14. Spine • Kyphosis, scoliosisorkyphoscoliosis: • Squaredvertebralbodies • Collapseorflattening of oneormorevertebrae • Asepticnecrosis, fracture, metastasis, osteomyelitis, osteoporosis • Vertebralpedicleerosionordestruction: • Bening bone tumor, granulomatousdisease, metastasis,

15. Resim koy

16. Differentialdiagnosis of localizedlesions of spine • Block vertebra: fusion of two or more vertebral bodies: • Variable grades of blocking from isolated hypoplasia of the intervertebral disk to complete fusion of bodies. • Decreased diameter of vertebrae at the side of segmentation defect, concavity of the anterior aspect of the block.

17. Blok vertebra

18. Spondylolisthesis: • Anterior slipping of one vertebral body on its subjacent neighbor while the posterior portions stay behind; is usually secondary to bilateral defects of pars interarticularis, called spondylolisis. • Spondylolysis is best demonstrated in oblique films.It may be a congenital failure of ossification or more likely traumatic, either an acute or a fatigue fracture.

19. spondilolizis Anterolisthesis of C6 on C7

20. Spine Imaging Guidelines 1. Uncomplicated LBP usually self-limited, requires no imaging 2. Consider imaging if: • Trauma • Cancer • Immunocompromise / suspected infection • Elderly / osteoporosis • Significant neurologic signs / symptoms 3. Back pain with signs / symptoms of spinal stenosis or radiculopathy, no trauma: • Start with MRI; use CT if: • Question regarding bones or surgical (fusion) hardware • Resolve questions / solve problems on MRI (typically use CT myelography) • MRI contraindicated

21. 4. Begin with plain films for trauma; CT to solve problems or to detail known fractures; MRI to evaluate soft-tissue injury (ligament disruption, cord contusion) 5. MRI for sx of radiculopathy, cauda equina syn, cord compression, myelopathy 6. Fusion hardware is safe for MRI but may degrade image quality; still worth a try 7. Indications for IV contrast in MRI: • Tumor, infection, inflammation (myelitis), any cord lesion • Post-op L-spine (discriminate residual/recurrent disk herniation from scar) 8. Emergent or scheduled? Emergent only if immediate surgical or radiation therapy decision needed (e.g. cord compression, cauda equina syndrome) 9. Difficult to image entire spine in detail; target study to likely level of pathology 10. CT chest/abdomen/pelvis includes T-L spine (no need to rescan trauma pts*) * If image data still on scanner (24-48 hours)

22. Spine pathology • Trauma • Degenerativedisease • Tumorsandothermasses • Inflammationandinfection • Vasculardisorders • Congenitalanomalies

23. Confusing “Spondy-” Terminology • Spondylosis = “spondylosisdeformans” = degenerativespine • Spondylitis = inflamedspine (e.g. ankylosing, pyogenic, etc.) • Spondylolysis = chronicfracture of pars interarticulariswithnonunion (“pars defect”) • Spondylolisthesis = anteriorslippage of vertebratypicallyresultingfrombilateral pars defects • Pseudospondylolisthesis = “degenerativespondylolisthesis” (spondylolisthesisresultingfromdegenerativediseaseratherthan pars defects)

24. Inflammatory lesions: • Pyogenic vertebral spondylitis: • Disk space narrowing • Loss of the normally sharp adjacent subchondral plates • Areas of cortical demineralization • Destruction of the vertebral body, possibly collapse • Sclerotic new bone formation, sometime spontaneous fusion.

25. spondilit

26. Spinaltuberculosis: • Involvement of thethoracolumbarormidthoracicspine, osteoporosis, largeparavertebralabcessrelativetotheamount of bone destruction, narrowing of oneormore disk spacesaftererosion of endplates, anteriorcompression of adjacentvertebra • Involvment of threeormorevertebralbodies, skiplesions in thespine, a largeorcalcifiedparaspinalmass

27. Spinal tbc

28. Disk degeneration: • The disk space is narrower than usual. Later the adjacent end-plates may become sclerotic and osteophytes develop. • A steak of gas within the disk space is indicative of the disk degeneration DISH (Diffuse idiopathic skeletal hyperostosis): • Flowing calcification and ossification along the anterolateral aspects of 4 or more contiuous vertebral bodies

30. Rheumatoid arthritis Change in order of apperance: • Joint effusion and periarticular edema • Periarticular osteoporosis • Joint space narrowing • Marginal erosions, pseudocysts • Compressive erosions • Subluxation and malalignment of joints, ulnar deviation, and flexion deformities in fingers and toes • Bony ankylosis, representing the end stage

32. Ankylosing spondylitis • Sacroiliac joints are bilaterally, symmetrically affected. • Initially loss of definition of joint margins followed by • Osteoporosis or sclerosis • Erosion and narrowing of joint space • Ankylosis

34. Ankylosing spondylitis • Radiographic Findings: • • SI Joint narrowing—Symmetric, may lead to fusion • • Pseudo-widening of the joint space • – Subchondral bone resorption—blurring • – Erosion sclerosis • – Calcification leading to ankylosis • • Bamboo spine • – Ossification of the anterior spinal ligament and ankylosis of the apophyseal joint • leading to complete fusion • • Syndesmophyte formation—Squaring of lumbar vertebrae’s anterior concavity • – Reactive bone sclerosis • – Squaring and fusion of the vertebral bodies and ossification of the annulus fibrosis atthe dorsolumbar and lumbosacral area • • Osteopenia—Bone wash-out • • Straightening of the C-spine • • Hip and shoulder involved to a lesser extent

36. Osteoarthritis • Nonuniform joint space narrowing, subchondral sclerosis and spur formations (osteophytes) are the hallmark of the disease. • Subchondral cysts are often present, while osteoporosis is characteristically absent

37. RADIOGRAPHIC FINDINGS: • • Asymmetric narrowing of the joint space • – Knee—medial joint space narrowing • – Hip—superior lateral joint space narrowing • • Subchondral bony sclerosis—new bone formation (white appearance, eburnation) • • Osteophyte formation • • Osseous cysts—microfractures may cause bony collapse • • Loose bodies • • No osteoporosis/osteopenia (no bone washout) • • Joint involvement • – First CMC • – DIP—Heberden’s • – Large joints—knee and hip • – Luschka joint’s—uncinate process on the superior/lateral aspect of the cervical vertebralbodies (C3-C5) making them concave

40. CT • Outstanding bone and soft tissue detail • The next imaging step after plain films for many conditions

41. CT Axial: Cervical • Much more sensitive and specific than plain films for osseous abnormalities

42. CT Sagittal Reformatting • Outstanding detail with no extra scanning • Computer generated from axial scan data

43. MRI • The Gold Standard for cord, thecal sac, nerve roots and disks; very good for ligament and osseous abnormalities, but not as sensitive as CT for some fractures

44. MRI • Outstanding for neural tissue, and for ligaments, tendons, joints, cartilages and muscle • Very sensitive for some bone conditions which are subtle or occult on plain films and CT

45. Degenerative Disease

47. Lumbar spinal stenosis

48. Disc bulge, facet hypertrophy and flaval ligament thickening • frequently combine to cause central spinal stenosis • Note the trefoil shape of stenotic spinal canal

49. Foraminal stenosis