Professional Documents
Culture Documents
Mri Spine
Mri Spine
Presented by:
• Composed of the central nucleus pulposus(NP), the peripheral annulus fibrosus(AF) and
the end plates(EP).
• The end plate is a bilayer of cartilage that separate the IVD from the vertebral
body(VB) and serves as growth plate for the VB.
NUCLEUS PULPOSUS:
– Highly hydrated structure, approx.
88% water
– Characterised by compressibility.
ANNULUS FIBROSUS
• Blood Supply
– the disk is avascular with capillaries terminating at
the end plates
– nutrition reaches nucleus pulposus
through diffusion through pores in the endplates
• annulus is not porous enough to allow
diffusion
• Innervation
– the dorsal root ganglion gives rise to the
sinuvertebral nerve which innervates
the superficial fibers of annulus
• no nerve fibers extend beyond the superficial
fibers
– neuropeptides thought to participate in sensory
transmission include
• substance P
• calcitonin
• VIP
• CPON
Distribution of load in the
inter-vertebral disc.
• Disc aging leads to an overall loss of water content and conversion to fibrocartilage. Specifically thereis
– decrease in
• nutritional transport
• water content
• absolute number of viable cells
• proteoglycans
• pH
– increase in
• an increase keratin sulfate to chondroitin sulfate ratio
• lactate
• degradative enzyme activity
• density of fibroblast-like cells
– fibroblast-like cells reside in the annulus fibrosus only
– no change in
• absolute quantity of collagen
SPECTRUM OF DEGENERATIVE JOINT
DISEASES OF SPINE
Disc herniation
Degenerative spondylolisthesis
Spinal stenosis
Living a sedentary lifestyle – more prone to herniated discs because the muscles that
support the back and neck weaken, which increases strain on the spine.
Traumatic injury to lumbar discs- commonly occurs when lifting while bent at the
waist, rather than lifting with the legs while the back is straight.
Tobacco abuse – toxins reduces the disc’s ability to absorb nutrients, which results in the
weakening of the disc.
Mutation- in genes coding for proteins involved in the regulation of the extracellular
matrix, such as MMP2 and THBS2,
Cellular and Biochemical Changes of the
Intervertebral Disc
Decrease proteoglycan
content.
Loss of negative charged
proteoglycan side chain.
Water loss within the
nucleus pulposus.
Decrease hydrostatic
property.
Loss of disc height.
Uneven stress
distribution on the annulus.
Thompson Grading( based on sagittal sections of
fresh cadaveric specimen)
Pfirmann Grading on MRI
MODIFIED PFIRMANN GRADING
MODIFIED PFIRMANN GRADING
Adam’s classification(based on discography)
ANNULAR TEARS
Concentric tears :
circumferential lesions, involves
outer layers of the annular wall.
Radial tears:
characterized by an annular tear
which permeates from the deep central part of
the disc (nucleus pulposus) and extends
outward toward the annulus, in either a
transverse or cranial-caudal plane.
Transverse tears:
also known as “peripheral tears” or “rim
lesions,” are horizontal ruptures of fibers, near
the insertion in the bony ring apophyses.
L4-L5 CT diskogram
demonstrating a large left
posterolateral radial anular tear
associated with a left foraminal and
extraforaminal herniaton
INTRAVERTEBRAL HERNIATIONS
Herniated discs in the cranio-caudal
(vertical) direction through a break in
one or both of the vertebral body
endplates are referred to as
“intravertebral herniations” (also
known as Schmorl’s nodes).
• Central prolapse:
– may present with back pain only or Cauda-
equina(severe cases)
L1 L2
Clinical Features- Neurology
L3
Clinical Features- Neurology
L4
Clinical Features- Neurology
L5
Trendelen
berg test
Clinical Features- Neurology
S1
Clinical Features- Red Flags
2. Simulation sign
3. Distraction sign
5. Overreaction(most
sensitive)
Differential Diagnosis
SPINAL CAUSES:
-Trauma
-Infection: Osteomyelitis or discitis ( with nerve root pressure)
-Inflammation: Arachnoiditis, ankylosing spondylitis
-Neoplasm: Benign or malignant with nerve root pressure(multiple myeloma,
extradural tumors)
EXTRASPINAL CAUSES:
• FINDINGS:
– Loss of lumbar lordosis
– Loss of disc height
X ray views
• Indirect Signs
– Disc space narrowing,
– Sclerosis of end plates
– Osteophytes
– Traction spur
– Vacuum Sign
• Direct signs
– Translational abnormalities on dynamic films
Vacuum sign
• radiolucent defect
• presence of nitrogen gas
accumulations in annular
and nuclear degenerative
fissures
• typical central vacuum
phenomenon gas
collection that fills large
neo-cavity occupying
both the nucleus an
annulus.
• indicative of advanced
disc degeneration.
CT scan
Advantages:
• provides superior imaging of cortical and trabecularbone
compared with MRI.
• It provides contrast resolution and identify root compressive
lesions such as disc herniation.
• differentiate between bony osteophyte from softdisc.
• diagnose foraminal encroachment of disc material due to its
ability to visualize beyond the limits of the dural sac and root
sleeves.
Limitations
• cannot differentiate between scar tissue and new disc
herniation
• does not have sufficient soft tissue resolution toallow
differentiation between annulus andnucleus
Investigations- MRI
• Most accurate and sensitive modality forthe diagnosis
of subtle spinalpathology.
• It allows direct visualization of herniated disc material
and its relationship toneural tissue including intrathecal
contents.
• Advantages over myelography
– No radiation
– Non invasive
– No intrathecal contrast
– More accurate in far lateraldisc
– Disc disease of LSjunction
– Early disc disease
Advantages of MRI over CT
– imaging the disc
– directly images neural structures
– shows the entire region of study (i.e.,cervical,
thoracic, or lumbar).
– ability to image the nerve root in the foramen
Limitations
– Showing abnormal anatomy in asymptomatic
patient.
– MRI findings can’t correlate with severityof
symptoms.
Indications for MRI
• pain lasting > one month and not
responding to non-operative management
or
• red flags are present
– infection (IV drug user, h/o of fever andchills)
– tumor (h/o or cancer)
– trauma (h/o car accident or fall)
– cauda equina syndrome (bowel/bladder changes)
Massive lumbar disc extrusion at L5–S1 in a 44-year-old man. Sagittal(a)
and axial (b) T1-weighted images; sagittal (c) and axial (d) T2-weighted
images. The extruded disc compresses and displaces the right S1nerve
root. On the sagittal T1-weighted image, the continuity between the
extruding portion and the parent disc can clearlybe identified.
GADOLINIUM ENHANCED CONTRAST MRI
• Complications
Epidural Steroid
injection Techniques
• Interlaminar Approach
• Transforaminal Approach
• CaudalApproach
Bed Rest
• no data to suggest that bed rest alters the
natural history of lumbar disc herniationor
improves outcomes.
• Consensus of 2 days (if used)
Semi Fowlers
Position
Physical Therapy
• Excercises
• Back School
• Others : IFT, SWD, TENS, Traction
Excercises
EXTENSION CONTROL
HAMSTRING STRETCH
KNEE ROLLS
Physical therapy
• TENS
– Trans-cutaneous electrical nerve stimulation
– release of endogenous analgesic endorphins
– Central nervous system process in which a control center is altered to
block transmission of pain
– Deyo RAet al ‘TENS is no different from a placebo’
• Intermittent Pelvic Traction
– Goal- distract the lumbar vertebrae.
– enlargement of the inter-vertebralforamen,
– creation of a vacuum to reduce herniateddiscs,
– placement of the PLLunder tension to aid in reduction of herniated
discs,
– relaxation of musclespasm,
– freeing of adherent nerveroots
– Does not alter naturalhistory of disease
Lifestyle Modifications
• Avoidance of
– Repetitive bending /twisting/ lifting
– Contact sports
– Heavy weights
– 2wheelers, Auto rickshaws
– Soft mattress( Spring, foam)
• Posture training
• Back support while sitting
• Firm mattress (rubberised foam, coir)
Intra-discal Electrothermal Therapy
• Low back pain of discogenic origin
• Not useful in radiculopathy
• posterolateral placement of a probe around the inner
circumference of the annulus followed by heating ofthe
probe.
• Pre Requisites
– Normal neurology
– Negative SLR.
– absence of compressive lesions on MRI
– positive concordant discogram
• Conflicting outcomes requiring refinement of indications
Operative management
• Standard discectomy
• Limited Discectomy
• Microsurgical Lumbar discectomy
• Endoscopic discectomy
• Additional Exposure
– Hemi laminectomy
– Total Laminectomy
– Facetectomy
• Percutaneous Discectomy
• Chemo-nucleolysis
• Arthrodesis
• Disc replacement
SURGICAL MANAGEMENT
• Indications
– persistent disabling pain lasting more than 6 weeks that have failed non-
operative options (and epidural injections)
– progressive and significant weakness
– Cauda-equina syndrome
• Rehabilitation
– patients may return to medium to high-intensity activity at 4 to 6 weeks
Contraindications
– Presence of sequestered fragments
– Lumbar canal stenosis
– Lumbosacral discs
Post op management
• Immediate post op
– Monitor neurology
– Turn in bed , semi fowler position
– Walk with assistance to toilet
– Oral analgesics and muscle relaxants for pain
– Bladder stimulants to assist invoiding
– Discharge- after walking and voiding(day of surgeryin
microscopic discectomy)
– minimize sitting and riding in a vehicle to comfort
– Increase walking on a daily basis
– Avoid stooping bending lifting
Post op management
• Delayed
– Core strengthening between week 1 & 3
– Lifting bending stooping gradually after 3weeks
– Long trips avoid for 4-6weeks
– Walking jobs with minimal lifting 2-3weeks
– Prolonged sitting jobs 4-6 weeks
– Heavy labor, long driving 6-8weeks
– Exceptionally heavy manual labour- AVOID
COMPLICATIONS
• Infection – Superficial wound
infection , Deep disc space infection
• Thrombophlebitis/ Deep vein
thrombosis
• Pulmonary embolism
• Dural tears may result in
Pseudomeningocoele, CSFleak,
Meningitis
• Postoperative cauda equine lesions
• Neurological damage or nerve root
injury
• Urinary retention and urinary tract
infection
CHEMONUCLEOLYSIS
Shrinkage of the
disc
Chemo nucleolysis
• Contraindications
– Sequestered disc
– Spinal stenosis
– previous injection of chymopapain
– allergy to papaya or itsderivatives;
– Previous surgical treatment of the lumbarspine;
– herniation of more than twodiscs;
– a rapidly progressive neurological deficit;
– neurogenic dysfunction of the bowel or the bladder, or both;
– spondylohisthesis.
– Spinal tumour
– Pregnancy
– Diabetic neuropathy
Chemo nucleolysis
• Complications
– Neurological
• cerebral hemorrhage,
• paraplegia,
• paresis, quadriplegia,
• Guillain-Barre syndrome,
• seizure disorder.
– Anaphylaxis
• Procedure is not in favournow
Disc Excision & Arthrodesis
• First suggested by Mixter and Barr
• Indicated for
– Marked segmental instability
– Done when facets are destabilized bilaterally to prevent
Iatrogenic Spondylolisthesis
• Disadvantages of fusion:
– Alters the biomechanics of spine
– Loss of motion and overall shift in the sagittal alignment
– Causes degenerative changes in the adjacent spinal
motion segments
Total Disc Replacement
• CHARITEartificial disc (Depuy spine) was the first
implant approved by FDAfor total disc
replacement in october 2004.
• Presently, there are only three lumbardisc
prostheses with FDAapproval:
– the INMOTION, which is a modification of theCharite
(Depuy Spine, Raynham, MA),
– the ProDisc-L (DePuySynthes),
– the activL (Aesculap, CenterValley,PA).