radiological assessment – part 2
TRANSCRIPT
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Cauda equina syndrome
30M 60F 70M
T2
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30M
T2 T1 T1FS con
T1 T1FS con
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60F
T2 T1 T1FS con
T1 T1FS con
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70M
T2 T1 T1FS con
T1 T1FS con
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35M PBA T2 T2 T1
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• 72 year old male • Non mechanical back pain • Known prostate Ca:
– Raised PSA (20) – Nodule on DRE – +ve on biopsy
• Staging investigations
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What is the most appropriate imaging modality for the spine?
1. Plain film 2. CT 3. Scintigraphy (bone scan) 4. MRI
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64F Breast Ca
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T2 T1 T1FS con
76M CRC
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T2
54M RCC
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• 62 year old male • Severe low back pain of rapid onset • Febrile and unwell • 4 weeks ago underwent abdominal surgery for
perforated diverticulitis
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What is the most likely diagnosis?
1. Acute disc herniation 2. Discitis/ osteomyelitis 3. Crush fracture secondary to osteoporosis 4. Metastatic cancer
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What is the most appropriate imaging modality?
1. Plain film 2. CT 3. Scintigraphy (bone scan) 4. MRI
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T2 T1 T1FS con
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T2 T1FS con
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• 37 year old male • Low back and buttock pain, increasing over
several months • Worse in morning; reduced by activity
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What is the most likely diagnosis?
1. Acute disc herniation 2. Facet joint degeneration 3. Inflammatory spondyloarthropathy 4. Metastatic cancer
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Seronegative spondyloarthropathies (SpA)
• European Spondyloarthropathy Study Group (ESSG) Arthritis Rheum 1991;34:1218-1227 – Ankylosing spondylitis – Reactive arthritis – Arthritis spondylitis with inflammatory bowel disease – Arthritis spondylitis with psoriasis – Undifferentiated spondyloarthropathy (uSpA)
• Clinical features + HLA-B27 • Rheumatoid factor –ve = seronegative
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ANKYLOSING SPONDYLITIS
• Chronic inflammatory disease, primarily affecting spine and sacroiliac joints
• Osteitis: – Bone erosions; sclerosis; ankylosis
• Peripheral arthritis: – Asymmetrical; lower limb
• Enthesopathy: – Plantar fasciitis – Distal Achilles tendonosis and paratendonitis
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DIAGNOSIS OF AS
• Radiographic grading of sacroiliitis 0-4 Kellegren Atlas of Standard Radiographs in Arthritis, Oxford
1963 • Grade 0 = normal • Grade 1 = suspicious (mild blurring) • Grade 2 = minimal sclerosis, some erosions • Grade 3 = severe erosions, joint widening, partial
ankylosis • Grade 4 = complete ankylosis
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Radiographic grading of AS • Grade 0 • Grade 1 • Grade 2 • Grade 3 • Grade 4
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Radiographic grading of AS • Grade 0 • Grade 1 • Grade 2 • Grade 3 • Grade 4
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Radiographic grading of AS • Grade 0 • Grade 1 • Grade 2 • Grade 3 • Grade 4
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Radiographic grading of AS • Grade 0 • Grade 1 • Grade 2 • Grade 3 • Grade 4
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Radiographic grading of AS • Grade 0 • Grade 1 • Grade 2 • Grade 3 • Grade 4
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Radiographic grading of AS • Grade 0 • Grade 1 • Grade 2 • Grade 3 • Grade 4
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Dx of AS: Modified New York criteria
• Arthritis Rheum 1984;27:361-368 • Clinical:
1. LBP & stiffness > 3/12 improved by exercise 2. ↓ motion lumbar spine sagittal and frontal 3. ↓ chest expansion for age & sex
• Radiological: – Grade ≥ 2 bilateral – Grade 3-4 unilateral
• AS = 2/3 clinical + radiological
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Problems with radiographic grading
• May take years for radiographic changes to develop – Early cases excluded from research and treatment
• Most radiographic signs in AS reflect healing processes, not disease activity – cf erosions in RA
• Most radiographic signs in AS irreversible • Radiographs do not detect inflammation
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T2FS
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T1 STIR
STIR
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Response to DMARD eg infliximab
– Braun Ann Rheum Dis 2002;61:iii51-iii60
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• 45 year old male • 2 weeks post discectomy L4/5 • Recurrent bilateral leg pain
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What is the most appropriate imaging modality?
1. Plain film 2. CT 3. Scintigraphy (bone scan) 4. MRI
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T2 T1
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T2
T1FS con
T2
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T1FS con
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• Dx: recurrent disc: – Central herniation + huge sequestration virtually filling
the spinal canal • Note peripheral enhancement pattern • DD: fibrosis
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• 51 year old female • Left sciatica
– Intermittent pain and paraesthesia
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T2 T1 T1FS con
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What is the most likely diagnosis?
1. Massive disc sequestration 2. Discitis complicated by abscess 3. Synovial cyst 4. Benign peripheral nerve sheath tumour
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T2 T1 T1FS con
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• Dx: benign peripheral nerve sheath tumour (BPNST) of left L3 nerve root – Many clinicians use the term ‘neuroma’
• Pathologically imprecise term – Most are benign
• Schwannoma or neurofibroma • Difficult (impossible) to differentiate on imaging
– BPNST is probably the best terminology – Associated with NF1 and ‘NF2’ (MISME)
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• 66 year old female • Severe lower back pain on and off for years • More recent (2 months) development of right
sciatica
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What is the most likely diagnosis?
1. Massive disc sequestration 2. Discitis complicated by abscess 3. Synovial cyst 4. Benign peripheral nerve sheath tumour
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L4/5
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• Severe OA of facet (zygoapophyseal) joints • Round heterogeneous lesion projecting into right
spinal canal • Note: close relationship to facet joint • Dx: synovial cyst
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Synovial cyst lumbar facet joint
• Fairly common • Key is relationship to degenerate facet joint • Density may vary from pure cyst to varying levels of
calcification and heterogeneity • Usually present clinically with intractable sciatica • May respond to aspiration and steroid injection, but
usually treated surgically
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T2 T1
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T2 T1
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Image interpretation: spine
• Anatomy • Cross sectional techniques:
– CT – MRI
• Nomenclature of disc herniations and spinal stenosis
• A few cases
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