Pioneer Batch  Class of 2012

MODULE Musculoskeletal Module DATE August 31, 2007

LECTURE Radiology: Imaging of the Back LECTURER Stephanie J.H. Pe, MD, FPCR

Topic Outline: B. Other views:

For evaluation of abnormalities (Back or neck pain,
Scoliosis, Trauma, other conditions)
- Spot film
I. Objectives - Flexion/Extension Views
II. Modalities (Review)
III. X-Rays of the Spine *Same STANDARD views (AP and lateral) for Cervical,
IV. Back and Spine Thoracic, and Lumbo-sacral region
Imaging Cheklist
V. Computed According to Moore and Dalley…
Tomography (CT Radiography
Scan) Examinations of the vertebral column usually
VI. Magnetic Resonance requires both AP and lateral views
Imaging (MRI) Conventional methods are excellent for high
VII. X-ray Myelography contrast structures like bone; advent of digital
VIII. Summary radiography allows improved contrast resolution

IV. Back and Spine Imaging Checklist

- Number of vertebrae (normal number and appearance)
- Shape
- Alignment
- Curvature
I. Objectives - Density/Signal intensity of Bone and other tissues
*Interpret NORMAL radiological images of the spine
based on knowledge of gross anatomy
A. Know appropriate modalities for imaging of the A B
spine
B. Identify structures of the spine from multiplanar
radiological images
• imaging is approached by sections e.g., thoracic, cervical,
etc.

II. Modalities (for the back):

A. most used: Xrays, CT scan, MRI
B. X-rays (radiographs)
C. Computed Tomography (CT Scan)
D. Magnetic Resonance Imaging
E. Ultrasound
F. Myelography, Arteriography, Venography

III. X-rays of the Spine

A. Standard:
Figure IV. (A) Radiograph of the lower back with abnormality.
- Antero-posterior (aka frontal view) view
(B) Radiograph of the lower back without abnormality.
- Lateral view (aka profile view)
- Oblique, right and left
o When necessary to view other structures
• intervening structures such as the IV discs and
spinal cord are not visible or resolved well in X-ray
radiographs
• there is a need to view the 2D images of X-rays
with a mindset of the true 3D image from the living
body

Page 1 of 6 Rx Men: Angustia-Ayes-Chan-Co-Garcia, N.

Macapinlac-Tumibay-Vega
 Pioneer Batch  Class of 2012
MODULE Musculoskeletal Module DATE August 31, 2007
LECTURE Radiology: Imaging of the Back LECTURER Stephanie J.H. Pe, MD, FPCR

Diff. b/n cervical and thoracic region

C Aside from number, on AP view – can see ribs
D Lateral view – ribs

Lumbar spine
1. more lardotic
2. Vertebral bodies do not have ribs attached to them

Figure IV. (C Figure IV. (D)

R)adiograph of the Extended Radiograph of the Flexed
Cervical Spine (Lateral view) Cervical Spine (Lateral view)

Figure IV. (H) Radiograph of the

lumber spine during lateral bending
(Anteroposterior view)

V. Computed Tomography (CT Scan)

Standard: Axial images (across the body, horizontal)
Computer reconstruction:
- Multi-planar (different planes)
- 3D

According to Moore and Dalley…

E
F CT
differentiates between white and grey
Figure IV. (E) Figure IV. (F) Radiograph matter of the brain and spinal cord
Radiograph of the Cervical of the Cervical Spine (AP
improved radiologic assessment of
Spine (Lateral view) view)
fractures of the vertebral column,
particularly in determining degree of
 images are 2d pictures, but have to imagine the structures compression of the Spinal cord
as 3d life-like structures
(McCormick, 2000)
 when you are familiar with the normal then you can
understand the abnormal images of vertebral column used to detect:
• fractures
• lesions
• congenital abnormalities
herniations and displaced fragments of IV
discs are recognizable

Figure IV. CT Scan “scannogram”

(G) Radiograph of the - diagram of where image was acquired
Thoracic Spine
- Bony structure is emphasized in the CT scan

Page 2 of 6 Rx Men: Angustia-Ayes-Chan-Co-Garcia, N.

Macapinlac-Tumibay-Vega
 Pioneer Batch  Class of 2012
MODULE Musculoskeletal Module DATE August 31, 2007
LECTURE Radiology: Imaging of the Back LECTURER Stephanie J.H. Pe, MD, FPCR

CT scan “3D reconstruction” figure

- useful for the surgeon to plan out before surgery

Advantages of CT
- emphasis on BONE DETAIL and CALCIFICATION
- No contraindication for metallic implants, pacemaker,
ambubag
- Faster than MRI

Figure V. (E) Normal anatomy on CT

- Axial image
- Use of scannogram to orient oneself as to where the image
Figure V. (A., B and C) CT scan = axial image of cervical vertebrae was taken

VI. MRI (Magnetic Resonance Imaging)

Standard Images are produced in 3 planes:
- Axial
- Sagittal
- Coronal images
- Computer reconstruction

Advantages of MRI
- Better SOFT TISSUE detail
- Intervertebral discs, spinal cord
- Early subtle changes/edema of bone and other tissues
- Bone contusions
- No harmful ionizing radiation

Figure V. (D) CT scan = axial image

= thoracic level

Page 3 of 6 Rx Men: Angustia-Ayes-Chan-Co-Garcia, N.

Macapinlac-Tumibay-Vega
 Pioneer Batch  Class of 2012
MODULE Musculoskeletal Module DATE August 31, 2007
LECTURE Radiology: Imaging of the Back LECTURER Stephanie J.H. Pe, MD, FPCR

Figure VI. (A) Normal anatomy on MRI

Figure VI. (E)

Sagittal MRI,
lateral view

C E
B

Figure VI. (B and C) Axial MRI image vs. Axial CT

image

MRI

Figure VI. (F)

MRI sagittal

Cervical spine:
 vertebrae
 spinal canal
 CSF
Figure VI. (D) Axial image figure. With Vertebra, Spinal canal, Paraspinal  Intervertebral disk
muscle (1-disc & vertebral body of L$; 2- exiting L4 root nerve; 3- L5 root
nerve; 4- thesal sac of cauda equine; 5- facet joint; 6- errector spinalis
muscle)
Page 4 of 6 Rx Men: Angustia-Ayes-Chan-Co-Garcia, N.
Macapinlac-Tumibay-Vega
 Pioneer Batch  Class of 2012
MODULE Musculoskeletal Module DATE August 31, 2007
LECTURE Radiology: Imaging of the Back LECTURER Stephanie J.H. Pe, MD, FPCR

G According to Moore and Dalley…

Magnetic Resonance Imaging

Like CT: computer-assisted; unlike CT: X-rays
are not used
Disadvantage: have to remain motionless inside
scanner for long periods of time  time spent is
markedly decreased now
Produces extremely good images of the vertebral
column, spinal cord, and CSF
Clearly demonstrates components of IV discs
and shows their relationship to the vertebral
bodies and longitudinal ligaments
• Imaging procedure of choice for
evaluating IV disc disorders
Herniations of the nucleus pulposus and its
relationship to the spinal nerve roots are also
well defined
Can demonstrate spinal cord or nerve root
compression and indicate the degree of
degenerative change within the IV disc
Figure VI. (G) MRI Cervical Spine axial Ideal screening procedure for the differential
view
diagnosis of structural disorders affecting the
spinal cord and spinal nerve roots

VII. X-ray Myelography

Iodinated contrast injection into the CSF space
- injection of contrast to enhance details in the radiograph

According to Moore and Dalley…

Myelography
Is a radiopaque contrast study that allows
visualization of the spinal cord and spinal nerve
roots
H Procedure: withdrawal of CSF by lumbar
puncture  contrast material injected into spinal
subarachnoid space
Shows extent of subarachnoid space and its
extensions around the spinal nerve roots within
the dural sheaths
Has largely been supplanted by high-resolution
MRI (McCormick et al., 2000)

VIII. Summary
Figure VI. (H) MRI Lumbar and Sacral Spine Sagital  X-ray, CT, and MRI are modalities most used for
imaging of the back and spine
 Images are 2-dimensional or flat, but must be
interpreted as 3-dimensional
Lumbar and sacral spine
 Have to be familiar with normal anatomy to be able to
Axial figure
Sagittal figure understand and assess images adequately
 Check for NORMAL: vertebral number, shape,
alignment, curvature, density/signal intensity of bone
and other tissues

Page 5 of 6 Rx Men: Angustia-Ayes-Chan-Co-Garcia, N.

Macapinlac-Tumibay-Vega
 Pioneer Batch  Class of 2012
MODULE Musculoskeletal Module DATE August 31, 2007
LECTURE Radiology: Imaging of the Back LECTURER Stephanie J.H. Pe, MD, FPCR

 Clinical history and Physical Examination are

important to be able to choose the appropriate Karing cabalen na rin ken! Jjver and harvey l.
imaging modality best suited to help diagnose the
patient’s problem Galing Rx-Men!

-END- PARA sa LAHAT,,, “May the f0rce be with us!” Go ASMPH

Batch 2012! Caluguran da kayu ngan!”,!

Sources: Merce: 114 days to go until Christmas!!

1. www.back2backchiropractic.com/xrays.htm
2. www.medscape.com AG: good morning baltimore!
3. www.surgeryencyclopedia.com/La-Pa/Myelography.html
4. Dalley, AF and Gold, DJ. 2005. Grant’s Dynamic Human
Anatomy, Student Version 2.0 CD, 11th ed. Philadelphia:
Lippincott Williams&Wilkins.
5. Moore KL and Dalley AF. 2006. Clinically Oriented
Anatomy, 5th ed. Philadelphia: Lippincott
Williams&Wilkins.

GREETINGS from the -Men:

Bam: belated happy birthday reg! advance happy birthday

to jose and choking!! ;P

Eds: Pag may tiyaga, may nilaga.;-)

Oliver: goodluck! Ü

Avs: goodluck to all of us

Nina: Hi :D Good Luck everyone!

Mackie: happy bday sa lahat ng September bday

celebrants… (special mention daw sina reg, merce and dan!
May suh0l ‘to! hehe!”,).. nxt time n pix ny0, mhaba ang
listahan eh, kulang sa space at ad fee…

hi na rin s mga olats(ecrem, reviilo, ihkkim?!) elitista at

dukha… sa mga co-SC (senior citizens-angkie, bangie,
margie, jijie at h0norary member-jeunnie and s mga on-
going applicants, di pa tap0s inititation ny0 kaya d p kay0
mentioned, hehe!”,). f0r all th0se wh0 wish to apply as SC
members and avail of the 20% discount in any food and
non-food establishments, approach ny0 lng kahit sin0 sa
mga pip0l mentioned, may age requirement dapt, 25 y/o up
per0 pwede ma-waive depende s usapan), may we have
many m0re “swimmings” and videoke sessions to c0me…

salamat na rin s mga sp0nsors k0 Dr Bing Mejia (manager

k0 rin ‘to) at Dra Grace Uy! At sa lahat ng mga ngbgay ng
mga nibblets and nibblers. Kay tita m2 aka vangie labalan
para sa mga acting tips.

Page 6 of 6 Rx Men: Angustia-Ayes-Chan-Co-Garcia, N.

Macapinlac-Tumibay-Vega