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CURRENT PATHOLOGY IMAGING GUIDELINES
CONTENTS
A. Neck and thoraxF. Spine
Imaging resources
1. Trauma 2. Infection 3. Tumor 4. Degenerative diseases 5. Malformations, scoliosis G. Extremities
Standing AP and lateral radiographs (very useful before any further imaging)
- static disorders: pelvis lateral tilt, scoliosis, exagerated kyphosis, hyperlordosis, rigidity, spondylolisthesis, subluxation
- vertebra and posterior elements: transitional abnormalities, malformations, fracture, avulsion, luxation, lytic or sclerotic lesions, osteopenia, collapse, posterior joint osteoarthritis, spinal stenosis
- vertebral discs: collapse, intradiscal gas, erosion or sclerosis of vertebral endplates, osteophytes
- soft tissues: paravertebral swelling, calcifications (post. longitudinal lig., yellow ligaments, annulus fibrosus, nucleus pulposus), paralytic ileus, aorta, etc.
- Other bone elements: sacrum, coccyx (better demonstrated by a localised lateral view), sacroiliac joints, pelvis, hips
Oblique views
- in cervical spine: visualisation of foramina, posterior facets
- in lumbar spine: allows analysis of vertebral isthms (spondylolysis)
Flexion-extension or lateral inclination (after standard views study)
- may show posttraumatic vertebral or posterior joints subluxation (cervical spine)
- anteroposterior stability disorders
- to distinguish a postural from a fixed scoliosis
- contraindications: fracture or luxation not excluded, dens subluxation (rheumatoid arthritis)
Transbuccal projection (A-P)
- C1-C2 joint
- dens and ligament lesions
Barsony projection
- sacroiliac joints (now better analysed by CT-scan)
- may show a spondylolysis at L5 level
- sacrum study
Myelography
- subarachnoidal space opacification through lumbar or suboccipital puncture
- almost always replaced by MRI sequences
Radiculography
- lumbosacral sac opacification through lumbar puncture
- sometimes useful before operation in addition to MRI in an ambiguous case (intraforaminal hernia, suspicion of recurrent disc hernia)
- often associated to CT-scan (myeloCT)
MRI
- after standard radiographs, best option for all spine segments, especially cervical spine (CT-scan images unsatisfactory due to shoulder artifacts) and long segments (dorsal column)
- suspicion of disc hernia recurrence after operation
- bone diseases (infection, inflammation, tumoral infiltration)
- best depiction of discal disorders, spinal canal lesions (tumors, collections, etc.) and paravertebral spaces
- myelographic sequences
CT-scan
- spine trauma
- good depiction of bony stenoses (older patients, severe osteoarthritis, suspicion of spinal canal stenosis)
- may be added to a myeloradiculography
- guidance in interventional radiology (diagnostic puncture, therapeutic infiltration, vertebroplasty)
- limited field of view, no direct sagittal sections, suboptimal tissue resolution (disc substance), less accurate for recurrent disc hernia
- most often replaced by MRI for: disc hernias, spondylodiscitis, neoplasia, operated patients
PROBLEM MANAGEMENT
1. Trauma
- CT-scan with multiplanar reconstructions: trauma work-up
- Plain films: osteopenia, fracture, bone avulsion, subluxation, luxation, angulation
- transbuccal: suspicion of dens fracture
- flexion views (cervical spine): posterior joints instability
- MRI: cord lesion, posterior wall, pathologic fracture, disc hernia, ligament injury
2. Infection
- Plain films: disc space narrowing, vertebral endplate erosion, scoliosis, paravertebral swelling
- MRI: first choice imaging tool for spondylodiscitis, extent of infection, paravetebral spread
- CT-scan: extent of bony destruction, abscess, guided puncture, drainage
- scintigraphy: search for occult infection site
3. Tumors
- Plain films: osteolysis, pathologic fractures, vertebral alignment, distant lesions, vertebral angioma
- MRI:tumor extension, spinal canal invasion, paravertebral invasion, skip lesions, treatment monitoring
- CT-scan: bone destruction, posterior elements, specific lesions (osteoblastoma, vertebral angioma, bone sclerosing metastasis), guided diagnostic punctures. Thoraco-abdominal metastatic work-up.
- scintigraphy: depiction of bone metastases (breast, prostate, lung, kidney, thyroid tumors, etc.)
4. Degenerative and inflammatory diseases
- Plain films: static disorders, malformations, disc space narrowing, osteophytosis, posterior elements osteoarthritits, osteopenia, vertebral collapse, erosion, calcification (DISH), ostéochondrosis (Scheuermann's disease)
- MRI: radiculalgia with neurological deficit (disc hernia, intracanalar synovial cyst, posterior joints osteoarthritits, foraminal stenosis), prolonged pain not responding to treatment, neurogenic claudication (spinal canal stenosis)
- CT-scan: may replace MRI for some lumbar spine indications (older or restless patients, complement after radiculography, infiltration guidance)
5. Malformation, scoliosis
- Plain films (for a scoliosis, 2 segments at least, i.e. cervical+thoracic or thoracic+lumbar, or total spine film); scoliosis angle measurements
- Obliques ± Barsony: spondylolisthesis
- Functional views: stability and reversibility of scoliosis, hyperkyphosis or hyperlordosis
- MRI: Chiari malformation, hydromyelia, tethered cord, sacrococcygian lipoma, meningocele
- CT-scan: complex vertebral malformations, diastematomyelia, post-operative status (strong metallic elements artifacts against MRI use)
- ultrasound (infants and small children): posterior arch closing defects and tethered cord.
Pierre Bénédict, MD, FMH radiologist, Lausanne, 1997-2018
References:
- Guide du bon usage de la SFR
- ACR (American College of Radiology) guidelines
- Radiation protection 118: Referral guidelines for imaging (Office for official publications of the European Communities)