Imaging Lumbar And

Front 1

standard lumbar xray views

Back 1

AP

lateral (flexion, extension)

right posterior oblique (to show the right facet and pars, and the LEFT SIJ)

left posterior oblique (to show the left facet and pars, and the right SIJ)

lumbar L5-S1 spot shot

Front 2

what is the lumbar AP xray reading process

Back 2

1. Identify T12 by finding the last rib and count down to sacrum
2. Trace the vertebral body for shape and color
3. Find the pedicles “eyes” at each level
4. Trace the spinous processes “nose” at each level
5. Trace the transverse processes “ears” at each level
6. Observe the disc spaces for size and color
7. Trace the sides of the vertebral bodies looking for bone spurs
8. Observe the soft tissues from the ribs to the iliac crest

Front 3

what is the lateral lumbar X ray reading process

Back 3

1. Trace the anterior edge of the vertebral bodies looking for bone spurs
2. Trace the individual vertebral bodies for shape and color
3. Observe the disc spaces for height and color
4. Trace the posterior edge of the vertebral bodies looking for slippage, ligament calcification or osteophytes (bone spurs)
5. Observe the pedicles
6. Observe facets for density and position
7. Trace the IVF’s
8. Trace the spinous process
9. Observe the soft tissue

Front 4

what is the lumbar flexion extension xray reading process

Back 4

1. Trace the anterior and posterior vertebral body lines looking for slippage
2. Look for symmetrical motion at each level

Front 5

what is the lumbar oblique xray reading process

Back 5

1. Trace the Scotty dog at each level
2. Look for radiolucent line through the pars “neck”
3. Observe the facets

Front 6

what is the L5-S1 spot shot X ray reading process

Back 6

These should be read with the same process listed above for the lateral and A/P films.

Front 7

what is spondylosis

Back 7

Non-uniform loss of joint space, osteophytes, subchondral sclerosis (hardening of the bone making it more radiodense/whiter on the x-ray), deformity and subluxation are the 5 general radiologic features of DJD.

Only two joint complexes in the lumbar spine undergo degenerative changes: the facet joints and the intervertebral discs.


An interruption of the pars interarticularis that may be unilateral or bilateral
A radiolucent defect in the pars interarticularis is visualized optimally on oblique and lateral lumbar radiographs
Referred to as the collar or broken neck of the “Scotty Dog”
Etiology
- Congenital, fatigue fracture, degenerative, traumatic

Front 8

where is the most common location of DJD

Back 8

L4-L5

Front 9

what is DDD

Back 9

degenerative disc disease

The major radiographic signs of disc degeneration include decrease in disc height, osteophyte formation, endplate sclerosis and subluxation.
Lateral films are the most helpful for identifying disc degeneration.

Front 10

what is spondylolisthesis

Back 10

An anterior displacement of a vertebral body in relation to the segment below
90% of all cases involve the fifth lumbar vertebrae

Normal: vertebral body corner aligns with sacral base corner.

Front 11

what is ankylosing spondylitis

Back 11

A chronic inflammatory disorder, predominately affecting younger males, which distinctively involves the axial skeleton
Age of onset is usually between 15 and 35 years of age (average of 26)

Characterized by:
Articular bony ankylosis (stiffening and fusing of bone), ligament ossification
Sacroiliac involvement is the hallmark of AS
Pseudowidening of the joint space
Loss of the articular cortical bone
Erosive and sclerotic changes
Irregular joint margins
Ankylosis


Spinal changes occur at the discovertebral junction, facet and costovertebral joints

The outer fibers of the annulus fibrosis and its attachment to the vertebral body undergo segmental ankylosis by the formation of syndesmophytes (ossification within ligamentous tissue)

Early ossification will show up as a “shiny corner sign”

When multiple segments are ankylosed by symmetric marginal syndesmophytes, the continuous undulating spinal contour is termed the bamboo spine

Front 12

signal intensity of the vertebral body in lumbar spine? discs? ligaments? SC and CSF?

Back 12

T1 image, the vertebral body will image bright
T2 image, the vertebral body will image low signal intensity

After radiation treatment, the bone marrow is replaced with fat and the vertebral bodies are brighter on T1 images


The spinal discs show low signal on T1, high signal on T2
The nucleus is brighter because of greater water content
Degenerative disc disease is a progressive decrease in signal intensity.

Ligaments:
The spinal ligaments demonstrate low signal intensity on T1 and T2 because of their high collagen content, except for the ligamentum flavum.

Spinal Cord and CSF:
T1 image the cord has an intermediate signal
T2 image the cord has a low signal
CSF low signal on T1 (lower than the spinal cord)
CSF high signal on T2

Front 13

lumbar sagittal MRI view

Back 13

1. Conus
2. Bone marrow
Normal bone marrow signal is higher than muscle or disc on T1
Marrow proliferation disorders
Multiple myeloma
Leukemia
Abnormal findings include a signal in the bone that is equal or lower than muscle on T1
3. Endplates
4. Disc: Hydrated, Desiccated or Displaced
5. Foramen

Front 14

lumbar axial MRI view

Back 14

1. Facets
2. Foramen
3. Disc
4. Spinal cord
5. Paraspinals, multifidi, quadratus lumborum and psoas
Look for atrophy, fat or abscesses
6. Look at the kidneys, renal arteries, aorta and inferior vena cava

Front 15

disc herniation, bulge, protrusion, extrusion

Back 15

Herniation:
A term originally meaning a focal protrusion, the meaning of which has become blurred, and which now seems to include bulge, protrusion, extrusion and osteophyte formation

Bulge:
Broad based disc displacement
Usually degenerative
No evidence that this occurs acutely
May be an incidental finding – presentation must correlate with clinical findings

Protrusion:
Focal disc displacement
Connection to native disc of similar dimension
May or may not be acute

Extrusion:
Focal disc displacement
Connection to native disc attenuated or absent
Sequestered or floating disc

Front 16

spinal stenosis

Back 16

Narrowing of the central spinal canal, neural foramen, lateral recess or any combination of these anatomic regions, by soft tissue or osseous structures that impinge on neural elements

Standard classification for stenosis is based on cause
• Congenital: (e.g., short pedicles)
• Acquired: degenerative
Causes of Spinal Stenosis
• Congenital
• Osteophytes
• Alignment abnormalities
• Ligament or facet hypertrophy
• Disc abnormalities
Levels of Stenosis
• Central
• Lateral recess
• Foraminal
Diagnosis
• Depends on size of canal
• Measurements are not always taken. The diagnosis is made via the shape of the canal and thecal sac. Normally round or oval on axial images
• Quantify as mild, moderate or severe
• Must correlate imaging studies with clinical examination
• May produce myelopathy or radiculopathy

Front 17

when do patients need Lumbar imaging

Back 17

Hx of Cancer and present w/cancer

Age > 50 w/1st time back pain, unexplained weight loss

Failure to respond to conservative tx.

MRI was no better at predicting these problems than an X-ray. Only time it was better for MRI was when there were these cauda equina sx’s
-Loss of B&B (bowel and bladder
-LE weakness
-Diminished or Absent LE reflexes

Front 18

what are the common views of the hip Xray

Back 18

AP
Unilateral AP
Lateral frog leg

Front 19

purpose and process of AP pelvis Xray

Back 19

Demonstrates the entire pelvis, sacrum, coccyx, SIJ, lumbosacral articulation, and both proximal femur and hip joints. Scout for trauma and identify the need for a unilateral AP of the hip.
• Trace the pelvic inlet (Males<90° females>90°)
• Observe bilateral lower 1/3 SIJ
• Observe and compare the shape and color of the ilium/sacrum
• Trace the femoral head in the acetabulum
• Visualize the acetabular roof along with the anterior and posterior acetabular rims (look for the cross-over sign)
• Look at the head-neck junction, angle of inclination - should be 125

Front 20

purpose and process of unilateral AP pelvis xray

Back 20

closer look at the hip joint. Identify all anatomical landmarks including the acetabulum, femoral head, neck, proximal 1/3 of the shaft, greater trochanter, and angle of inclination of the femoral neck to the shaft (125-135°).
• Trace Shenton’s Line – smooth curve along the medial and superior surface of the obturator foramen to the medial aspect of the femoral neck.
• Trace the iliofemoral line – trace a smooth curve from the greater trochanter along the femoral neck up through the outer surface of the ilium (may help in the identification of disorders at the head-neck junction, i.e. slipped capital femoral epiphysis)
• Radiographic Teardrop – formed by the cortical surfaces of the ischium and the pubis, representing the anteroinferior aspect of the acetabulum.

Front 21

XXX purpose and process of lateral frog leg pelvis xray

Back 21

Demonstrates the femoral head, neck, and proximal 1/3 of the femoral shaft and greater and lesser trochanters from the medial aspect.
Cross-Table Lateral – Identify the same landmarks as the frog-leg lateral view. Used in patients who cannot rotate their leg to the position of the frog-leg.
• Viewing the femur from medial to lateral
• Lesser trochanter is anterior, and the greater trochanter is superimposed behind the femoral neck
• Able to see more of the femoral head
• Acetabular roof and anterior/posterior rims still visible

Front 22

what is DDH

Back 22

Developmental Dysplasia of the Hip (DDH) –as inability of acetabulum and femoral head to form a congruent articulation.

Identify the angle of inclination (>175°)
Identify Shenton’s line
A smooth curve drawn from the medial neck of the femur to the inferior border of the superior pubic ramus
on xray

Front 23

what is legg-calve perthese disease

Back 23

Legg-Calve-Perthes Disease (LCP) – Essentially AVN in the pediatric hip
infarction of the bony epiphysis of the femoral head. LCPD represents idiopathic avascular necrosis of the femoral head.

Short history of
Painful limp: Flex, Abd, ER
Reduced mobility
Muscle atrophy
Trendelenburg test positive
Leads to adult DJD

Small obturator foramen
Increased medial hip joint space
Small femoral head
Crescent sign
Subcondral fracture with nitrogen gas collection
On the femoral head
Epiphyseal fragmentation

slight widening of the hip joint, representing a small joint effusion. Joint widening can also be secondary to hypertrophy of the cartilage.

Front 24

what is scfe

Back 24

Slipped Capital Femoral Epiphysis (SCFE) – trace Shenton’s line and look at the head neck junction


Slipping of the neck on the femoral head

Xray: Asymmetrical growth plate
Medial slippage of the femoral epiphysis
Surgical stabilization is required

Front 25

what is avascular necrosis

Back 25

necrosis of the femoral head secondary to trauma, infection, prolonged steroid use, chemotherapy, etc. Femoral head receives blood supply from foveal artery in the ligamentum teres. Neck of the femur receives blood supply from the circumflex femoral arteries.

Front 26

what is a pelvic fracture

Back 26

– location of the fracture determines the patient’s prognosis (intracapsular vs. extracapsular) based on the vascular structures that may affect the overall healing process (potentially leading to AVN).

Front 27

what is pelvic OA

Back 27

Remember the 5 signs common for degenerative joint disease from earlier in the semester. Included in your assessment should be the identification of any medial migration of the femoral head (protrusion acetabuli).

Front 28

what is trochanteric bursitis

Back 28

?

Front 29

what are the common views for Ankle X ray

Back 29

1. AP
2. AP Mortise
3. Lateral Weightbearing or Non-weightbearing
4. Oblique

Front 30

what is the position for Ankle AP Xray view and reading process

Back 30

AP View
The patient is supine with the heel resting on the film cassette. The foot is in a neutral position. The central beam is directed vertically to the ankle joint at the midpoint between both malleoli.
Identify:
1. Distal tibia
2. Distal fibula
3. Distal tibiofibular joint
4. Ankle Mortise
5. Medial malleolus
6. Lateral malleolus – superimposed behind the lateral aspect of the tibia
7. Dome of the talus
Medial or lateral shift of the talus in the mortise may indicate the presence of laxity, instability, or a fracture at the ankle.

Front 31

what is the position for ankle AP mortise view Xray and reading process

Back 31

Demonstrates the entire mortise view. The leg is internally rotated 15°-20° to place both malleoli in the same plane, avoiding superimposition of the lateral aspect of the tibia over the fibula.
Identify:
1. Distal tibia
2. Distal fibula
3. Dome of the talus
4. Entire ankle mortise
Abnormal widening of the mortise or displacement of the talus may indicate the presence of ligamentous laxity, injury, or ankle fracture.

Front 32

what is the position for ankle lateral view Xray and reading process

Back 32

The patient can be WB or NWB, the fibula is resting on the film cassette and the foot is in the neutral position. The central beam is directed vertically to the medial malleolus.
Identify:
1. Distal tibia
2. Distal fibula superimposed behind the tibia and the talus
3. Talus
4. Calcaneus
5. Navicular, Cuboid, Base of the 5th Metatarsal
6. Can also see tibiotalar, calcaneocuboid, talonavicular, and talocalcaneonavicular (subtalar) joints

Front 33

what is the position and reading process for ankle oblique view Xray

Back 33

The patient is supine and the foot and leg are internally rotated approximately 35-45°. The foot is in the neutral position. The central beam is directed perpendicular to the lateral malleolus.
Identify:
1. Distal tibiofibular syndesmosis
2. Distal fibula
3. Lateral malleolus
Distinguish the oblique view from the mortise view based on the angle of the foot on the film.

Front 34

what are the common views for foot xray

Back 34

1. AP
2. Lateral
3. Oblique

Front 35

what is the position and reading process for foot AP view Xray

Back 35

The patient is supine with the knee flexed, and the sole of the foot placed firmly on the film cassette. The central beam is directed vertically through the base of the third metatarsal.
Identify:
1. Phalanges with corresponding PIP and DIP joints
2. Metatarsals with corresponding MTP and tarsometatarsal joint
3. Cuneiforms
4. Cuboid
5. Navicular
6. Sesamoid bones
7. Transverse tarsal joints
8. First inter-metatarsal angle: 5-15° (Looking for presence of hallux valgus and other deformities caused by different angulation)

Front 36

what is the position and reading process for foot Lateral view Xray

Back 36

The patient can be WB or NWB, with the fibula resting on the film cassette and the foot in a neutral position. The central beam is directed vertically through the base of the third metatarsal.
Identify:
1. Subtalar joints
2. Transverse tarsal joints
3. Tarsometatarsal joint

Front 37

XXX what is the position and reading process for foot oblique view Xray

Back 37

The patient is supine on the table with the knee flexed. The lateral border of the foot is elevated 40°-45° from the film cassette. The central beam is directed vertically through the base of the third metatarsal.
Identify:
1. Phalanges, Metatarsals
2. Intermetatarsal joints
3. 3rd Cuneiform (lateral cuneiform)
4. Navicular, Cuboid
5. Talus, Calcaneus

Front 38

what are the MRI views for the foot and ankle

Back 38

Axial
Coronal
Sagittal

Front 39

during an MRI of the foot and ankle you should ID

Back 39

Identify:
Anterior Muscles/Tendons:
1. Anterior tibialis
2. Extensor Hallucis Longus
3. Extensor Digitorum Longus
4. Peroneus/fibularis Tertius

Medial Muscles/Tendons
1. Tibialis Posterior
2. Flexor Digitorum Longus
3. Flexor Hallucis Longus

Lateral mm./tendons
1. Peroneus/fibularis longus
2. Peroneus/fibularis brevis

Posterior mm./tendons
1. Achilles tendon
2. Gastrocnemius
3. Soleus

Front 40

when is ankle imaging indicated?

Back 40

, if there is tenderness over the crests or midportions of the malleoli (ankle series) or the navicular or base of the fifth metatarsal (foot series) or if there is inability to bear weight both immediately after injury and during examination.