Back Clinic Chiropractic Examination. An initial chiropractic examination for musculoskeletal disorders will typically have four parts: a consultation, case history, and physical examination. Laboratory analysis and X-ray examination may be performed. Our office provides additional Functional and Integrative Wellness Assessments in order to bring greater insight into a patient’s physiological presentations.
Consultation:
The patient will meet the chiropractor which will assess and question a brief synopsis of his or her lower back pain, such as:
Duration and frequency of symptoms
Description of the symptoms (e.g. burning, throbbing)
Areas of pain
What makes the pain feel better (e.g. sitting, stretching)
What makes the pain feel worse (e.g. standing, lifting).
Case history. The chiropractor identifies the area(s) of complaint and the nature of the back pain by asking questions and learning more about different areas of the patient’s history, including:
Family history
Dietary habits
Past history of other treatments (chiropractic, osteopathic, medical and other)
Occupational history
Psychosocial history
Other areas to probe, often based on responses to the above questions.
Physical examination: We will utilize a variety of methods to determine the spinal segments that require chiropractic treatments, including but not limited to static and motion palpation techniques determining spinal segments that are hypo mobile (restricted in their movement) or fixated. Depending on the results of the above examination, a chiropractor may use additional diagnostic tests, such as:
X-ray to locate subluxations (the altered position of the vertebra)
A device that detects the temperature of the skin in the paraspinal region to identify spinal areas with a significant temperature variance that requires manipulation.
Laboratory Diagnostics: If needed we also use a variety of lab diagnostic protocols in order to determine a complete clinical picture of the patient. We have teamed up with the top labs in the city in order to give our patients the optimal clinical picture and appropriate treatments.
Most people don�t even think about visiting a chiropractor until they�ve sustained an injury or need a quick adjustment to help ease the pain. They typically see it as a treatment for injuries or conditions that they�ve already endured, not as a preventative health care option. And while chiropractic care is an exceptional way to treat existing conditions and injuries, that is only half of the picture. It is also a viable health care approach that is effective in improving overall wellness. There are some very compelling reasons to incorporate chiropractic into your everyday life. Chiropractic can:
Help lower your risk of injury
When the spine is out of alignment, it can put stress on other parts of the body including ligaments and joints. Regular chiropractic care helps keep the spine aligned thus reducing your risk of injury.
Elevate your mood
Chiropractic treatment can help to balance your hormones. It increases the feel-good hormone dopamine while decreasing the stress hormone cortisol. It makes it an excellent drug-free option for patients who suffer from anxiety, depression, or mood swings. As part of your treatment, your chiropractor may also recommend dietary and lifestyle changes that can help even more.
Makes you feel more energetic
When your spine is out of alignment, your entire body suffers. You can feel stiff, sore, and fatigues. Most patients report feeling invigorated after their treatment. They can move more naturally and have much more energy. Part of this is due to the effect the treatment has on the body as well as the hormones that are released that provide a boost in your mood.
Help you sleep better
More than 60 percent of people in the United States, both children, and adults report having problems with sleep. Studies show that chiropractic can help with insomnia allowing you to get better, more restful, and more beneficial sleep.
The combination of pain alleviation, increased flexibility, and overall wellness, as well as stress relieving properties, allow your body and mind to relax so that you can fall asleep easier and stay asleep. Incorporating chiropractic care into your everyday routine can help you get a better night�s sleep.
Strengthen your immune system
Studies show that patients who receive regular chiropractic care have a significantly stronger immune system than patients who don�t see a chiropractor. One of the most significant studies to date that explored the connection between regular chiropractic care and a healthy immune system conducted by Dr. Ronald Pero, Ph. D. of New York�s Preventive Medicine Institute where he was the chief of cancer research. He was also a professor of medicine at New York University. The study, which spanned several years, found that patients who received chiropractic care on a regular basis had a 200 percent greater immune competence than non-chiropractic patients.
Manage your pain
Chronic pain, as well as pain from injuries or certain conditions, respond very well to regular chiropractic care. Any discomfort can negatively impact your quality of life, but pain medications can have unpleasant side effects that can be debilitating. It doesn�t help that many pain medications are highly addictive.
Treatments offer a natural remedy for pain that is medication free. What�s more, regularly scheduled therapies work to fix the cause of the problem so that the issue gets permanently resolved.
Make you feel better without medication
Chiropractic treatments are non-invasive and drug-free. It uses the body�s healing properties to address issues naturally and achieve results. It is low risk and very useful, treating the cause of problems, not just the symptoms the way pain medication does.
When you look at all of the benefits of regular chiropractic care and realize that those results can be achieved naturally, it�s easy to see why more people are incorporating it into their health care routines.
While computed tomography scanning, or CT scans, of the cervical spine are frequently utilized to help diagnose neck injuries, simple radiographs are still commonly performed for patients who have experienced minor cervical spine injuries with moderate neck pain, such as those who have suffered a slip-and-fall accident. Imaging diagnostic assessments may reveal underlying injuries and/or aggravated conditions to be more severe than the nature of the trauma. The purpose of the article is to demonstrate the significance of cervical spine radiographs in the trauma patient.�
Abstract
Significant cervical spine injury is very unlikely in a case of trauma if the patient has normal mental status (including no drug or alcohol use) and no neck pain, no tenderness on neck palpation, no neurologic signs or symptoms referable to the neck (such as numbness or weakness in the extremities), no other distracting injury and no history of loss of consciousness. Views required to radiographically exclude a cervical spine fracture include a posteroanterior view, a lateral view and an odontoid view. The lateral view must include all seven cervical vertebrae as well as the C7-T1 interspace, allowing visualization of the alignment of C7 and T1. The most common reason for a missed cervical spine injury is a cervical spine radiographic series that is technically inadequate. The �SCIWORA� syndrome (spinal cord injury without radiographic abnormality) is common in children. Once an injury to the spinal cord is diagnosed, methylprednisolone should be administered as soon as possible in an attempt to limit neurologic injury.
Radiographs continue to be used as a first-line imaging diagnostic assessment modality in the evaluation of patients with suspected cervical spine injuries. The aim of cervical spine radiographs is to confirm the presence of a health issue in the complex structures of the neck and define its extent, particularly with respect to instability. Multiple views may generally be necessary to provide optimal visualization.
Dr. Alex Jimenez D.C., C.C.S.T.
Introduction
Although cervical spine radiographs are almost routine in many emergency departments, not all trauma patients with a significant injury must have radiographs, even if they arrive at the emergency department on a backboard and wearing a cervical collar. This article reviews the proper use of cervical spine radiographs in the trauma patient.
Low-risk criteria have been defined that can be used to exclude cervical spine fractures, based on the patient’s history and physical examination.1�6 Patients who meet these criteria (Table 1) do not require radiographs to rule out cervical fractures. However, the criteria apply only to adults and to patients without mental status changes, including drug or alcohol intoxication. Although studies suggest that these criteria may also be used in the management of verbal children,7�9 caution is in order, since the study series are small, and the ability of children to complain about pain or sensory changes is variable. An 18-year-old patient can give a more reliable history than a five-year-old child.
Some concern has been expressed about case reports suggesting that �occult� cervical spine fractures will be missed if asymptomatic trauma patients do not undergo radiography of the cervical spine.10 On review, however, most of the reported cases did not meet the low-risk criteria in Table 1. Attention to these criteria can substantially reduce the use of cervical spine radiographs.
Cervical Spine Series and Computed Tomography
Once the decision is made to proceed with a radiographic evaluation, the proper views must be obtained. The single portable cross-table lateral radiograph, which is sometimes obtained in the trauma room, should be abandoned. This view is insufficient to exclude a cervical spine fracture and frequently must be repeated in the radiographic department.11,12 The patient’s neck should remain immobilized until a full cervical spine series can be obtained in the radiographic department. Initial films may be taken through the cervical collar, which is generally radiolucent. An adequate cervical spine series includes three views: a true lateral view, which must include all seven cervical vertebrae as well as the C7-T1 junction, an anteroposterior view and an open-mouth odontoid view.13
If no arm injury is present, traction on the arms may facilitate visualization of all seven cervical vertebrae on the lateral film. If all seven vertebrae and the C7-T1 junction are not visible, a swimmer’s view, taken with one arm extended over the head, may allow adequate visualization of the cervical spine. Any film series that does not include these three views and that does not visualize all seven cervical vertebrae and the junction of C7-T1 is inadequate. The patient should be maintained in cervical immobilization, and plain films should be repeated or computed tomographic (CT) scans obtained until all vertebrae are clearly visible. The importance of obtaining all of these views and visualizing all of the vertebrae cannot be overemphasized. While some missed cervical fractures, subluxations and dislocations are the result of film misinterpretation, the most frequent cause of overlooked injury is an inadequate film series.14,15
In addition to the views listed above, some authors suggest adding two lateral oblique views.16,17 Others would obtain these views only if there is a question of a fracture on the other three films or if the films are inadequate because the cervicothoracic junction is not visualized.18 The decision to take oblique views is best made by the clinician and the radiologist who will be reviewing the films.
Besides identifying fractures, plain radiographs can also be useful in identifying ligamentous injuries. These injuries frequently present as a malalignment of the cervical vertebrae on lateral views. Unfortunately, not all ligamentous injuries are obvious. If there is a question of ligamentous injury (focal neck pain and minimal malalignment of the lateral cervical x-ray [meeting the criteria in Table 2]) and the cervical films show no evidence of instability or fracture, flexion-extension views should be obtained.17,19 These radiographs should only be obtained in conscious patients who are able to cooperate. Only active motion should be allowed, with the patient limiting the motion of the neck based on the occurrence of pain. Under no circumstance should cervical spine flexion and extension be forced, since force may result in cord injury.
Although they may be considered adequate to rule out a fracture, cervical spine radiographs have limitations. Up to 20 percent11,20,21 of fractures are missed on plain radiographs. If there is any question of an abnormality on the plain radiograph or if the patient has neck pain that seems to be disproportionate to the findings on plain films, a CT scan of the area in question should be obtained. The CT is excellent for identifying fractures, but its ability to show ligamentous injuries is limited.22 Occasionally, plain film tomography may be in order if there is a concern about a type II dens fracture (Figure 1).
While some studies have used magnetic resonance imaging (MRI) as an adjunct to plain films and CT scanning,23,24 the lack of wide availability and the relatively prolonged time required for MRI scanning limits its usefulness in the acute setting. Another constraint is that resuscitation equipment with metal parts may not be able to function properly within the magnetic field generated by the MRI.
Cervical Spine Radiography
Figure 2 summarizes the approach to reading cervical spine radiographs.
Lateral View
Alignment of the vertebrae on the lateral film is the first aspect to note (Figure 3). The anterior margin of the vertebral bodies, the posterior margin of the vertebral bodies, the spinolaminar line and the tips of the spinous processes (C2-C7) should all be aligned. Any malalignment (Figures 4 and 5) should be considered evidence of ligamentous injury or occult fracture, and cervical spine immobilization should be maintained until a definitive diagnosis is made.
Confusion can sometimes result from pseudosubluxation, a physiologic misalignment that is due to ligamentous laxity, which can occur at the C2-C3 level and, less commonly, at the C3-C4 level. While pseudosubluxation usually occurs in children, it also may occur in adults. If the degree of subluxation is within the normal limits listed in Table 2 and the neck is not tender at that level, flexion-extension views may clarify the situation. Pseudosubluxation should disappear with an extension view. However, flexion-extension views should not be obtained until the entire cervical spine is otherwise cleared radiographically.
After ensuring that the alignment is correct, the spinous processes are examined to be sure that there is no widening of the space between them. If widening is present, a ligamentous injury or fracture should be considered. In addition, if angulation is more than 11 degrees at any level of the cervical spine, a ligamentous injury or fracture should be assumed. The spinal canal (Figure 2) should be more than 13 mm wide on the lateral view. Anything less than this suggests that spinal cord compromise may be impending.
Next, the predental space�the space between the odontoid process and the anterior portion of the ring of C1 (Figure 2)�is examined. This space should be less than 3 mm in adults and less than 4 mm in children (Table 2). An increase in this space is presumptive evidence of a fracture of C1 or of the odontoid process, although it may also represent ligamentous injury at this level. If a fracture is not found on plain radiographs, a CT scan should be obtained for further investigation. The bony structures of the neck should be examined, with particular attention to the vertebral bodies and spinous processes.
The retropharyngeal space (Figure 2) is now examined. The classic advice is that an enlarged retropharyngeal space (Table 2) indicates a spinous fracture. However, the normal and abnormal ranges overlap significantly.25 Retropharyngeal soft tissue swelling (more than 6 mm at C2, more than 22 mm at C6) is highly specific for a fracture but is not very sensitive.26 Soft tissue swelling in symptomatic patients should be considered an indication for further radiographic evaluation. Finally, the craniocervical relationship is checked.
Odontoid View
The dens is next examined for fractures. Artifacts may give the appearance of a fracture (either longitudinal or horizontal) through the dens. These artifacts are often radiographic lines caused by the teeth overlying the dens. However, fractures of the dens are unlikely to be longitudinally oriented. If there is any question of a fracture, the view should be repeated to try to get the teeth out of the field. If it is not possible to exclude a fracture of the dens, thin-section CT scans or plain film tomography is indicated.
Next, the lateral aspects of C1 are examined. These aspects should be symmetric, with an equal amount of space on each side of the dens. Any asymmetry is suggestive of a fracture. Finally, the lateral aspects of C1 should line up with the lateral aspects of C2. If they do not line up, there may be a fracture of C1. Figure 6 demonstrates asymmetry in the space between the dens and C1, as well as displacement of the lateral aspects of C1 laterally.
Anteroposterior View
The height of the cervical spines should be approximately equal on the anteroposterior view. The spinous processes should be in midline and in good alignment. If one of the spinous processes is off to one side, a facet dislocation may be present.
Common Cervical Abnormalities
The most common types of cervical abnormalities and their radiographic findings are listed in Table 3. Except for the clay shoveler’s fracture, they should be assumed to be unstable and warrant continued immobilization until definitive therapy can be arranged. Any patient found to have one spinal fracture should have an entire spine series, including views of the cervical spine, the thoracic spine and the lumbosacral spine. The incidence of noncontiguous spine fractures ranges up to 17 percent.27,28 Figures 7 through 9 demonstrate aspects of common cervical spine fractures.
Initial Treatment of Cervical Spine and Cord
If a cervical fracture or dislocation is found, orthopedic or neurosurgical consultation should be obtained immediately. Any patient with a spinal cord injury should begin therapy with methylprednisolone within the first eight hours after the injury, with continued administration for up to 24 hours. Patients should receive methylprednisolone in a dosage of 30 mg per kg given intravenously over one hour. Over the next 23 hours, intravenous methylprednisolone in a dosage of 5.4 mg per kg per hour should be administered. This therapy has been shown to improve outcomes and minimize cord injury,29 although it is not without its problems. The incidence of pneumonia is increased in patients treated with high dosages of methylprednisolone.30
�Sciwora� Syndrome: Unique in Children
A special situation involving children deserves mention. In children, it is not uncommon for a spinal cord injury to show no radiographic abnormalities. This situation has been named �SCIWORA� (spinal cord injury without radiographic abnormality) syndrome. SCIWORA syndrome occurs when the elastic ligaments of a child’s neck stretch during trauma. As a result, the spinal cord also undergoes stretching, leading to neuronal injury or, in some cases, complete severing of the cord.31 This situation may account for up to 70 percent of spinal cord injuries in children and is most common in children younger than eight years. Paralysis may be present on the patient’s arrival in the emergency department. However, up to 30 percent of patients have a delayed onset of neurologic abnormalities, which may not occur until up to four or five days after the injury. In patients with delayed symptoms, many have neurologic symptoms at the time of the injury, such as paresthesias or weakness, that have subsequently resolved.32
It is important to inform the parents of young patients with neck trauma about this possibility so that they will be alert for any developing symptoms or signs. Fortunately, most children with SCIWORA syndrome have a complete recovery, especially if the onset is delayed.33 It is possible to evaluate these injuries with MRI, which will show the abnormality and help determine the prognosis: a patient with complete cord transection is unlikely to recover.3
The treatment of SCIWORA syndrome has not been well studied. However, the general consensus is that steroid therapy should be used.34 In addition, any child who has sustained a significant degree of trauma but has recovered completely should be restricted from physical activities for several weeks.34
Cervical spine radiographs include three standard views, such as the coned odontoid peg view, the anteroposterior view of the entire cervical spine, and the lateral view of the entire cervical spine. Most qualified and experienced healthcare professionals, including chiropractors, offer additional views to visualize the cervicothoracic junction as well as to evaluate the proper alignment of the spine in all patients.�
Dr. Alex Jimenez D.C., C.C.S.T.
About the Authors
MARK A. GRABER, M.D., is associate professor of clinical family medicine and surgery (emergency medicine) at the University of Iowa Hospitals and Clinics, Iowa City. He received his medical degree from Eastern Virginia Medical School, Norfolk, and served a residency in family medicine at the University of Iowa College of Medicine, Iowa City.
MARY KATHOL, M.D., is associate professor of radiology at the University of Iowa Hospitals and Clinics. She is also head of the musculoskeletal radiology section. She received her medical degree from the University of Kansas School of Medicine, Kansas City, Kan., and served a residency in radiology at the University of Iowa College of Medicine.
Address correspondence to Mark A. Graber, M.D., Department of Family Medicine, Steindler Bldg., University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242. Reprints are not available from the authors.
In conclusion,�it is essential to evaluate all views of the cervical spine through imaging diagnostic assessments. While cervical spine radiographs can reveal injuries and conditions, not all neck injuries are detected through radiography. Computed tomography, or CT, scans of the cervical spine are highly accurate in the diagnosis of neck fractures which can help with treatment. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topics: Acute Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
1.�Kreipke DL, Gillespie KR, McCarthy MC, Mail JT, Lappas JC, Broadie TA. Reliability of indications for cervical spine films in trauma patients.�J Trauma. 1989;29:1438�9.
2.�Ringenberg BJ, Fisher AK, Urdaneta LF, Midthun MA. Rational ordering of cervical spine radiographs following trauma.�Ann Emerg Med. 1988;17:792�6.
3.�Bachulis BL, Long WB, Hynes GD, Johnson MC. Clinical indications for cervical spine radiographs in the traumatized patient.�Am J Surg. 1987;153:473�8.
4.�Hoffman JR, Schriger DL, Mower W, Luo JS, Zucker M. Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study.�Ann Emerg Med. 1992;21:1454�60.
5.�Saddison D, Vanek VW, Racanelli JL. Clinical indications for cervical spine radiographs in alert trauma patients.�Am Surg. 1991;57:366�9.
6.�Kathol MH, El-Khoury GY. Diagnostic imaging of cervical spine injuries.�Seminars in Spine Surgery. 1996;8(1):2�18.
7.�Lally KP, Senac M, Hardin WD Jr, Haftel A, Kaehler M, Mahour GH. Utility of the cervical spine radiograph in pediatric trauma.�Am J Surg. 1989;158:540�1.
8.�Rachesky I, Boyce WT, Duncan B, Bjelland J, Sibley B. Clinical prediction of cervical spine injuries in children. Radiographic abnormalities.�Am J Dis Child. 1987;141:199�201.
9.�Laham JL, Cotcamp DH, Gibbons PA, Kahana MD, Crone KR. Isolated head injuries versus multiple trauma in pediatric patients: do the same indications for cervical spine evaluation apply?�Pediatr Neurosurg. 1994;21:221�6.
10.�McKee TR, Tinkoff G, Rhodes M. Asymptomatic occult cervical spine fracture: case report and review of the literature.�J Trauma. 1990;30:623�6.
11.�Woodring JH, Lee C. Limitations of cervical radiography in the evaluation of acute cervical trauma.�J Trauma. 1993;34:32�9.
12.�Spain DA, Trooskin SZ, Flancbaum L, Boyarsky AH, Nosher JL. The adequacy and cost effectiveness of routine resuscitation-area cervical-spine radiographs.�Ann Emerg Med. 1990;19:276�8.
13.�Tintinalli JE, Ruiz E, Krome RL, ed. Emergency medicine: a comprehensive study guide. 4th ed. New York: McGraw-Hill, 1996.
15.�Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed cervical spine injuries.�J Trauma. 1993;34:342�6.
16.�Apple JS, Kirks DR, Merten DF, Martinez S. Cervical spine fractures and dislocations in children.�Pediatr Radiol. 1987;17:45�9.
17.�Turetsky DB, Vines FS, Clayman DA, Northup HM. Technique and use of supine oblique views in acute cervical spine trauma.�Ann Emerg Med. 1993;22:685�9.
18.�Freemyer B, Knopp R, Piche J, Wales L, Williams J. Comparison of five-view and three-view cervical spine series in the evaluation of patients with cervical trauma.�Ann Emerg Med. 1989;18:818�21.
19.�Lewis LM, Docherty M, Ruoff BE, Fortney JP, Keltner RA Jr, Britton P. Flexion-extension views in the evaluation of cervical-spine injuries.�Ann Emerg Med. 1991;20:117�21.
20.�Mace SE. Emergency evaluation of cervical spine injuries: CT versus plain radiographs.�Ann Emerg Med. 1985;14:973�5.
21.�Kirshenbaum KJ, Nadimpalli SR, Fantus R, Cavallino RP. Unsuspected upper cervical spine fractures associated with significant head trauma: role of CT.�J Emerg Med. 1990;8:183�98.
22.�Woodring JH, Lee C. The role and limitations of computed tomographic scanning in the evaluation of cervical trauma.�J Trauma. 1992;33:698�708.
23.�Schaefer DM, Flanders A, Northrup BE, Doan HT, Osterholm JL. Magnetic resonance imaging of acute cervical spine trauma. Correlation with severity of neurologic injury.�Spine. 1989;14:1090�5.
24.�Levitt MA, Flanders AE. Diagnostic capabilities of magnetic resonance imaging and computed tomography in acute cervical spinal column injury.�Am J Emerg Med. 1991;9:131�5.
25.�Templeton PA, Young JW, Mirvis SE, Buddemeyer EU. The value of retropharyngeal soft tissue measurements in trauma of the adult cervical spine. Cervical spine soft tissue measurements.�Skeletal Radiol. 1987;16:98�104.
26.�DeBehnke DJ, Havel CJ. Utility of prevertebral soft tissue measurements in identifying patients with cervical spine fractures.�Ann Emerg Med. 1994;24:1119�24.
29.�Bracken MB, Shepard MJ, Collins WF Jr, Holford TR, Baskin DS, Eisenberg HM, et al. Methylprednisolone or naloxone treatment after acute spinal cord injury: 1-year follow-up data. Results of the second National Acute Spinal Cord Injury Study.�J Neurosurg. 1992;76:23�31.
30.�Galandiuk S, Raque G, Appel S, Polk HC Jr. The two-edged sword of large-dose steroids for spinal cord trauma.�Ann Surg. 1993;218:419�25.
31.�Grabb PA, Pang D. Magnetic resonance imaging in the evaluation of spinal cord injury without radiographic abnormality in children.�Neurosurgery. 1994;35:406�14.
32.�Pang D, Pollack IF. Spinal cord injury without radiographic abnormality in children�the SCIWORA syndrome.�J Trauma. 1989;29:654�64.
33.�Hadley MN, Zabramski JM, Browner CM, Rekate H, Sonntag VK. Pediatric spinal trauma. Review of 122 cases of spinal cord and vertebral column injuries.�J Neurosurg. 1988;68:18�24.
34.�Kriss VM, Kriss TC. SCIWORA (spinal cord injury without radiographic abnormality) in infants and children.�Clin Pediatr. 1996;35:119�24.
The editors of AFP welcome the submission of manuscripts for the Radiologic Decision-Making series. Send submissions to Jay Siwek, M.D., following the guidelines provided in �Information for Authors.�
Coordinators of this series are Thomas J. Barloon, M.D., associate professor of radiology and George R. Bergus, M.D., assistant professor of family practice, both at the University of Iowa College of Medicine, Iowa City.
Many types of arthritis can affect the structure and function of the muscles, bones and/or joints, causing symptoms such as, pain, stiffness and swelling. While arthritis can commonly affect the hands, wrists, elbows, hips, knees and feet, it can also affect the facet joints found along the length of the spine. One of the most well-known types of arthritis, known as rheumatoid arthritis or RA, is a chronic inflammatory disease of the joints which occurs when the human body’s own immune system attacks the synovium, the thin membrane that lines the joints. According to the article below, imaging the spine in arthritis is fundamental towards its proper treatment.
Abstract
Spinal involvement is frequent in rheumatoid arthritis (RA) and seronegative spondyloarthritides (SpA), and its diagnosis is important. Thus, MRI and CT are increasingly used, although radiography is the recommended initial examination. The purpose of this review is to present the typical radiographic features of spinal changes in RA and SpA in addition to the advantages of MRI and CT, respectively. RA changes are usually located in the cervical spine and can result in serious joint instability. Subluxation is diagnosed by radiography, but supplementary MRI and/or CT is always indicated to visualize the spinal cord and canal in patients with vertical subluxation, neck pain and/or neurological symptoms. SpA may involve all parts of the spine. Ankylosing spondylitis is the most frequent form of SpA and has rather characteristic radiographic features. In early stages, it is characterized by vertebral squaring and condensation of vertebral corners, in later stages by slim ossifications between vertebral bodies, vertebral fusion, arthritis/ankylosis of apophyseal joints and ligamentous ossification causing spinal stiffness. The imaging features of the other forms of SpA can vary, but voluminous paravertebral ossifications often occur in psoriatic SpA. MRI can detect signs of active inflammation as well as chronic structural changes; CT is valuable for detecting a�fracture.
The spine can be involved in most inflammatory disorders encompassing rheumatoid arthritis (RA), seronegative spondyloarthritides (SpA), juvenile arthritides and less frequent disorders such as, arthro-osteitis and SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome.
During the last decade, the diagnostic use of magnetic resonance imaging (MRI) and computed tomography (CT) has increased considerably, although radiography is still the recommended initial examination. It is therefore important to know the characteristic radiographic findings in arthritides in addition to the advantages of supplementary MRI and CT. This review will focus on the different imaging features and be concentrated on the most frequent inflammatory spinal changes seen in RA and SpA, respectively. These two entities display somewhat different imaging features, which are important to recognize.
Rheumatoid arthritis is an autoimmune disease which causes the human body’s own immune system to attack and often destroy the lining of the joints. Although it commonly affects the small joints of the hands and feet, rheumatoid arthritis, or RA, can affect any joint in the human body. The neck, or cervical spine, can be affected more often than the lower back if rheumatoid arthritis affects the joints in the spine.�
Dr. Alex Jimenez D.C., C.C.S.T.
�
Rheumatoid Arthritis
Involvement in RA is usually located in the cervical spine where erosive changes are predominantly seen in the atlanto-axial region. Inflamed and thickened synovium (pannus) can occur around the odontoid process (dens) and cause bone erosion and destruction of surrounding ligaments, most seriously if the posterior transverse ligament is involved. Laxity or rupture of the transverse ligament causes instability with a potential risk of spinal cord injury. Cervical RA involvement is a progressive, serious condition with reduced lifetime expectancy [1], and its diagnosis is therefore important [2, 3].
Fig. 1 Standard radiography of the cervical spine in rheumatoid arthritis (RA). (a) Lateral radiographs in neutral position and (b) during flexion in addition to (c) lateral and (d) anterior-posterior (AP) open-mouth view of the atlanto-axial region (45-year-old woman). The flexion view (b) shows abnormal distance (>3 mm) between the posterior aspect of the anterior arc of the atlas and the anterior aspect of the dens (black line). Note that the spino-laminar line of the atlas�(arrow) does not align with that of the other vertebrae, confirming the presence of anterior subluxation, but there is no stenosis of the atlanto- axial canal; the posterior atlanto-dental interval (white line) is >14 mm. The open-mouth view (d) shows erosion at the base of the dens (arrow). (a) and (b) show concomitant disc degenerative changes at the C4�C6 level.
Fig. 2 Lateral and rotatory atlanto-axial subluxation. AP open- mouth view in a 53-year-old man with RA. There is narrowing of the atlanto-axial joints with superficial erosions (black arrow) and lateral displacement of the axis with respect to the lateral masses of the atlas (white arrow); in addition signs indicating rotatory displacement with asymmetry of the distance between the dens and the lateral masses of the atlas.
Radiography of the cervical spine is mandatory in RA patients with neck pain [3]. It should always include a�lateral view in a flexed position compared with a neutral position in addition to special views of the dens area to detect any lesions and/or instability (Fig. 1). A supplementary lateral view during extension can be useful to assess reducibility of atlanto-axial subluxation possibly limited by pannus tissue between the anterior arc of the atlas and dens.
Anterior atlanto-axial subluxation is the most frequent form of RA instability in the occipito-atlanto-axial region, but lateral, rotatory and vertical subluxation can also occur. The definition of the different forms of instability by radiography is as follows [3].
Anterior atlanto-axial subluxation. Distance between the posterior aspect of the anterior arc of the atlas and the anterior aspect of the dens exceeding 3 mm in a neutral position and/or during flexion (Fig. 1). It may cause stenosis of the atlanto-axial canal presenting as a posterior atlanto-dental interval<14 mm (Fig. 1).
Lateral and rotatory atlanto-axial subluxation.�Displacement of the lateral masses of the atlas more than 2 mm in relation to that of the axis and asymmetry of the lateral masses relative to the dens, respectively (Fig. 2). Rotatory�and lateral subluxation is diagnosed on open-mouth anterior-posterior (AP) radiographs. Anterior subluxation often coexists because of the close anatomical relation between the atlas and the axis.
Posterior atlanto-axial subluxation. The anterior arc of the atlas moves over the odontoid process. This is rarely seen, but may coexist with fracture of the dens.
Vertical atlanto-axial subluxation is also referred to as atlanto-axial impaction, basilar invagination or cranial�setting, and is defined as migration of the odontoid tip proximal to McRae�s line corresponding to the occipital foramen. This line can be difficult to define on radiographs, and vertical subluxation has therefore also been defined by several other methods. Migration of the tip of the odontoid process >4.5 mm above McGregor�s line (between the postero-superior aspect of the hard palate and the most caudal point of the occipital curve) indicates vertical subluxation (Fig. 3).
Fig. 3 Vertical atlanto-axial subluxation, measurement methods. (a) Lateral normal radiograph in neutral position showing the location of McGregor�s line (black) between the postero-superior aspect of the hard palate and the most caudal point of the occipital curve. Migration of the tip of the dens >4.5 mm above McGregor�s line indicates vertical subluxation. The distance indicated by the white line between McGregor�s line and the midpoint of the inferior margin of the body of axis is used to evaluate vertical subluxation according to Redlund-Johnell and Pettersson�s method. A distance less than 34 mm in men and 29 mm in women indicates vertical subluxation. (b) Sagittal CT�reconstruction of a normal cervical spine showing the location of McRae�s line corresponding to the occipital foramen and the division of the axis into three equal portions used by Clark�s method for diagnosing vertical subluxation. If the anterior arc of the atlas is in level with the middle or caudal third of the axis there is slight and pronounced vertical subluxation, respectively. (c) Ranawat�s method includes determination of the distance between the centre of the second cervical pedicle and the transverse axis of the atlas. A distance less than 15 mm in males and 13 mm in females indicates vertical subluxation [4].
Fig. 4 Vertical subluxation. (a) Lateral radiograph with McGregor�s line (black line; 61-year-old man with RA). The tip of the dens is difficult to define, but measurement according to Redlund-Johnell�s method (white line) results in a distance of 27 mm, which is below the normal limit. In accordance with this, the anterior arc of the atlas is level with the middle third of the axis. (b) Ranawat�s method, the distance between the centre of the second cervical pedicle and the transverse axis of the atlas is below the normal limit (9 mm). Thus, all measurements indicate vertical subluxation. Supplementary MRI, (c) sagittal STIR and (d) T1-weighted images show erosion of the dens and protrusion of the tip into the occipital foramen causing narrowing of the spinal canal to 9 mm, but persistence of cerebrospinal fluid around the cord. There is a 9-mm-thick mass of pannus tissue between the dens and anterior arc (black line) exhibiting small areas with high signal intensity on the STIR image (arrow) compatible with slight activity, but signal void fibrous pannus tissue predominates.
The occurrence of dens erosion can, however, make this measurement difficult to obtain. The Redlund-Johnell method is therefore based on the minimum distance between McGregor�s line and the midpoint of the inferior margin of the body of the axis on a lateral radiograph in a neutral position (Fig. 3) [4]. Visualisation of the palate may not always be obtained. Methods without dens and/or the palate as landmarks have therefore been introduced [4]. The method described by Clark et al. (described in [4]) includes assessment of the location of the atlas by dividing the axis into three equal portions on a lateral radiograph. Location of the anterior arc of the atlas in level with the middle or caudal third of the axis indicates vertical subluxation (Fig. 3). Ranawat et al. have proposed using the distance between the centre of the second cervical pedicle and the�transverse axis of the atlas at the odontoid process (Fig. 3) [4]. To obtain the diagnosis of vertical subluxation a combination of the Redlund-Johnell, Clark and Ranawat methods has been recommended (described in [4]). If any of these methods suggests vertical subluxation MRI should be performed to visualize the spinal cord (Fig. 4). Using this combination of methods vertical subluxation will be missed in only 6% of patients [4]. It is mandatory to diagnose vertical subluxation; this can be fatal because of the proximity of the dens to the medulla oblongata and the proximal portion of the spinal cord. Risk of cord compression/injury occurs, especially in patients with flexion instability accompanied by erosive changes in the atlanto- axial and/or atlanto-occipital joints, causing the vertical subluxation with protrusion of the dens into the occipital foramen (Figs. 4, 5).
Subaxial RA changes also occur in the form of arthritis of the apophyseal and/or uncovertebral joints, appearing as narrowing and superficial erosions by radiography. It can cause instability in the C2-Th1 region, which is mainly seen in patients with severe chronic peripheral arthritis. Anterior subluxation is far more frequent than posterior subluxation. It is defined as at least 3 mm forward slippage of a vertebra�relative to the underlying vertebra by radiography including a flexion view (Fig. 6). Changes are particularly characteristic at the C3�4 and C4�5 level, but multiple levels may be involved, producing a typical �stepladder� appearance on lateral radiographs. The condition is serious if the subaxial sagittal spinal canal diameter is <14 mm, implying a possibility of spinal cord compression [2]. The instability may progress over time, especially if the C1�C2 region is stabilized surgically (Fig. 6) [5].
Fig. 5 Vertical subluxation with spinal cord compression. MRI of the cervical spine in a 69- year-old woman with advanced peripheral RA, neck pain and clinical signs of myelopathy. (a) Sagittal STIR, (b) sagittal T1 and (c) axial T2 fat-saturated (FS) images show erosion of the dens and protrusion of the tip into the occipital foramen causing compression of the spinal cord, which exhibits irregular signal intensity (white arrows). The osseous spinal canal has a width of approximately 7 mm (black line). There is heterogeneous signal intensity pannus surrounding the dens compatible with a mixture of fibrotic and oedematous pannus tissue (black arrows) in the widened space between the dens and the anterior arc of the atlas.
Discitis-like changes and spinous process erosion may also be detected by radiography in RA, but are relatively rare, whereas concomitant degenerative changes occur occasionally (Fig. 1).
Cross-sectional imaging in the form of CT and MRI eliminates overprojecting structures and can improve the detection of RA changes. Osseous changes (erosions, etc.) can be clearly delineated by CT [6]. Additionally, MRI visualizes soft tissue structures (pannus; spinal cord, etc.), signs of disease activity and sequelae of inflammation in the form of fibrous pannus. These advantages of CT and MRI in patients with atlanto-axial involvement are illustrated in Figs. 7 and 8, including the possibility of detecting signs of arthritis by MRI before the occurrence of erosive changes (Fig. 8) [3].
Fig. 6 Subaxial instability. (a) Flexion view in a 64-year-old woman with advanced peripheral RA showing anterior atlanto-axial instability as well as subaxial instability at multiple levels. (b) Flexion view 2 years later after surgical stabilization of the atlanto-axial region demonstrates progression of the subaxial instability, especially between C3 and C4 (white arrow). There is a characteristic �stepladder� appearance, which also occurred on the initial radio- graphs (a), but is less pronounced.
Fig. 7 Advantages of CT and MRI. (a) Supplementary CT and (b-f) MRI of the patient shown in Fig. 1. CT demonstrates erosion not only at the base of the dens, but also at the tip and at the atlanto-axial and atlanto-occipital joints, which are difficult to visualize by radiography. MRI, (b) sagittal STIR and (c) sagittal T1 of the entire cervical spine and post-contrast T1FS images of the atlanto-axial region, (d) sagittal, (e) coronal and (f) axial. Oedematous voluminous pannus surrounding the dens is seen on the STIR and T1 images (black arrows) in addition to C4/5 and C5/6 disc degeneration with posterior protrusion of the disc at C4/5. The post-contrast T1FS images confirm the presence of vascularized enhancing pannus around the dens (white arrows) and demonstrate improved anatomical delineation compared with the STIR image. There is no sign of spinal cord compression.
Fig. 8 Non-radiographic MR findings. MRI in a 41-year-old woman with peripheral erosive RA and neck pain, but normal cervical radiography. (a) Post-contrast axial and (b) coronal TIFS images show signs of active arthritis with synovial contrast enhancement at the left atlanto-axial joint in addition to enhancing pannus tissue at the left side of the dens (white arrows). There is also a subchondral enhancing area in the axis (black arrow) compatible with a pre-erosive lesion.
A diagnostic strategy according to Younes et al. [3] is recommended (Fig. 9). This includes an indication for radiography in all RA patients with disease duration >2 years as cervical involvement may occur in over 70% of patients and has been reported to be asymptomatic in 17% of RA patients. It is recommended to monitor patients with manifest peripheral erosions accompanied by RF (rheumatoid factor) and antiCCP (antibodies to cyclic citrullinated peptide) positivity every second year and�patients with few peripheral erosions and RF negativity at 5-year intervals. MRI is indicated in patients with neurological deficit, radiographic instability, vertical subluxation and subaxial stenosis [2, 3]. Visualisation of the spinal cord is especially important to detect cord injury or risk of injury. MRI should therefore always be performed in RA patients with neck pain and/or neurological symptoms [3, 7].
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Seronegative Spondyloarthritides
According to European classification criteria [8, 9], SpA is divided into: (1) ankylosing spondylitis (AS), (2) psoriatic arthritis, (3) reactive arthritis, (4) arthritis associated with inflammatory bowel disorders (enteropathic arthritis) and (5) undifferentiated SpA. Inflammatory changes at the sacroiliac joints always occur in AS and are part of most other forms of SpA. Spinal changes are also a feature of SpA, especially in the late stages of AS.
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Ankylosing Spondylitis
Ankylosing spondylitis is the most frequent and usually the most disabling form of SpA. It has a genetic predisposition in the form of a frequent association with the human leukocyte antigen (HLA) B27 [10]. AS often starts in early adulthood and has a chronic progressive course. It is therefore important to diagnose this disorder. According to the modified New York Criteria [11], the diagnosis of definite AS requires the following: manifest sacroiliitis by radiography (grade ?2 bilateral or unilateral grade 3�4 sacroiliitis; Fig. 10) and at least one of the following clinical criteria: (1) low back pain and stiffness for more than 3 months improving with activity, (2) limited movement of the lumbar spine and (3) reduced chest expansion. These criteria are still used in the diagnosis of AS despite the increasing use of MRI to detect the disease early. It is therefore important to know both the characteristic radiographic features and the MR features of AS.
Early radiographic spinal changes encompass erosion of vertebral corners (Romanus lesions) causing vertebral squaring and eliciting reactive sclerosis appearing as condensation of vertebral corners (shiny corners; Fig. 10). These changes are caused by inflammation at the insertion of the annulus fibrosus (enthesitis) at vertebral corners provoking reactive bone formation [12]. Later on slim ossifications appear in the annulus fibrosus (syndesmo- phytes) (Fig. 11) [13]. With disease progression the spine gradually fuses because of syndesmophytes crossing the intervertebral spaces in addition to fusion of apophyseal joints, resulting in complete spinal fusion (bamboo spine;�Fig. 12). In advanced disease the supra- and interspinous ligaments may ossify and be visible on frontal radiographs as a slim ossified streak (Fig. 12). The occurrence of a single central radiodense streak has, the �dagger sign�. When the ligamentous ossification occurs together with ossification of apophyseal joint capsules, there are three vertical radiodense lines on frontal radiography (trolley-track sign).
Fig. 9 Diagnostic strategy. According to Younes et al. [3] radiography of the cervical spine is indicated in all RA patients with disease duration >2 years. It should at least include open-mouth and lateral views in neutral and flexed positions. Because of the occurrence of asymptomatic cervical involvement in 17% of RA patients, it is recommended to monitor patients with intervals of 2�5 years depending on positivity for the rheumatoid factor. MRI is indicated in patients with neurological deficit, radiographic instability, atlanto-axial impaction and subaxial stenosis. CT may add information in rotatory and lateral subluxation because of the possibility of secondary reconstruction in arbitrary planes and a clear visualisation of the atlanto-occipital joints [6].
Erosive changes within intervertebral spaces (Andersson lesions) have been detected by radiography in approximately 5% of patients with AS [14], but more frequently by MRI (Fig. 11) [15].
Persistent movement at single intervertebral spaces may occur in an otherwise ankylosed spine, sometimes caused by non-diagnosed fractures. This can result in pseudo- arthrosis-like changes with the formation of surrounding reactive osteophytes due to excessive mechanical load at single movable intervertebral spaces [14]. The diagnosis of such changes may require a CT examination to obtain adequate visualization (Fig. 13).
One of the life-threatening complications of AS is spinal fracture. Non-fatal fractures have been reported to occur in up to 6% of AS patients, especially in patients with long disease duration [16]. Fractures may occur after minor trauma because of the spinal stiffness and frequently accompanying osteoporosis. Fractures often occur at intervertebral spaces, but usually involve the ankylosed posterior structures and are thereby unstable (Fig. 14). Obvious fractures can visualize by radiography, but fractures may be obscured. It is therefore mandatory to supplement a negative radiography with CT if fracture is suspected (in the case of trauma history or a change in spinal symptoms). The occurrence of cervico-thoracic fractures may cause spinal cord injury and be lethal even following minor trauma [17].
Cross-sectional CT or MR imaging can be advantageous in the diagnosis of AS changes. CT providing a clear delineation of osseous structures is the preferred technique for visualizing pseudo-arthrosis and detecting fractures (Figs. 13, 14). CT is superior to MRI in detecting minor osseous lesions such as erosion and ankylosis of the apophyseal, costo-vertebral and costo-transversal joints (Fig. 15). MRI can visualize signs of active inflammation in the form of bone marrow and soft tissue oedema and/or contrast enhancement. It has therefore gained a central role in the evaluation of disease activity [15]. MRI can, however, also detect sequelae of inflammation consisting of fatty deposition in the bone marrow and chronic structural changes such as erosion and fusion of vertebral bodies [15].
Characteristic MR findings early in the disease are activity changes mainly consisting of oedema at vertebral corners and/or costo-vertebral joints (Fig. 16) [13]. The inflammatory changes at vertebral corners are characteristic of AS. Based on the occurrence of severe or multiple (?3) lesions in young patients, AS changes can be distinguished from degenerative changes with a high reliability [18].
Fig. 10 Relatively early changes in ankylosing spondylitis (AS). (a) AP radiograph of the sacroiliac joints in a 28-year-old man presenting with typical definite bilateral AS sacroiliitis (grade 3) in the form of bilateral joint erosion accompanied by subchondral sclerosis. (b) Initial spinal changes consisting of erosion of vertebral corners (Romanus lesion) with vertebral squaring corresponding to Th11, Th12, L4 and L5 accompanied by condensation of the vertebral corners�shiny corners (arrows).
During the disease course signs of activity can also occur at syndesmophytes, apophyseal joints and interspinous ligaments (Fig. 16). Detection of inflammation at apophyseal joints by MRI, however, demands pronounced involvement�histopathologically [19]. The inflammation at vertebral corners is the most valid feature and has been observed related to the development of syndesmophytes by radiography [12], establishing a link between signs of disease activity and chronic structural changes.
Chronic AS changes detectable by MRI mainly consist of fatty marrow deposition at vertebral corners (Fig. 17), erosion (Fig. 11) and vertebral fusion in advanced disease (Fig. 12). Fatty marrow deposition seems to be an a sign of chronicity being significantly correlated with radiographic changes, in particular, vertebral squaring [15]. Erosions are more frequently detected by MRI than by radiography (Fig. 11) [15] and can present with signs of active inflammation and/or surrounding fatty marrow deposition compatible with sequels of osseous inflammation. Syndesmophytes, however, may not always be visible by MRI because they may be difficult to distinguish from fibrous tissue unless there is concomitant active inflammation or fatty deposition (Figs. 11, 16) [15, 20].
The possibility of visualizing disease activity by MRI has increased its use to monitor AS, especially during anti-TNF (anti-tumour necrosis factor) therapy [21, 22]. Several studies have shown that MR changes are frequent in the thoracic spine (Fig. 16) [15, 23]. It is therefore important to examine the entire spine using sagittal STIR or T2 fat-saturated (FS) and T1-weighted sequences. Supplementary axial slices can be necessary for visualising involvement of apophyseal, costo-vertebral and costo-transversal joints (Fig. 16) [24, 25]. Post-contrast T1FS sequences can sometimes be advantageous as they provide better anatomical delineation [26]. Additionally, dynamic contrast-enhanced MRI may be superior to static MRI in monitoring disease activity during anti-TNF therapy [27]. Whole-body MRI gives the possibility of detecting involvement in other areas without losing important information about spinal and sacroiliac joint involvement [28, 29].
Other Forms of SpA
Radiographic changes in reactive and psoriatic arthritis are often characterized by voluminous non-marginal syndesmophytes (parasyndesmophytes) or coalescing ossification of the paravertebral ligaments in addition to asymmetrical sacroiliitis (Fig. 18) [30].
Reactive arthritis is self-limiting in most patients. However, in patients with chronic reactive arthritis and HLA B27 the axial changes may progress to changes somewhat similar to those seen in AS and can then be regarded as AS elicited by infection [10].
Fig. 11 Syndesmophytes and erosions in AS. (a) Lateral radiograph in a 29-year-old man with the characteristic slim ossification (syndesmophytes) at the periphery of the annulus fibrosus (black arrows) in addition to erosion of the endplates at the intervertebral (iv) space between L3 and L4 (white arrow). Supplementary MRI, (b) sagittal STIR and (c) T1-weighted images show small oedematous areas in the�erosion at iv L3/4 on the STIR image and surrounding fatty marrow deposition on T1 as a sign of previous osseous inflammation. There are additional erosive changes (black arrows, c) not clearly delineated by radiography and slight oedema at the vertebral corners (white arrows, b). Note that the syndesmophytes demonstrated by radiogra- phy are not visible on MRI.
Fig. 12 Advanced AS. (a) AP and (b) lateral radiograph in a 55-year-old man showing vertebral fusion due to syndesmophytes crossing the intervertebral spaces in addition to fusion of the apophyseal joints (bamboo spine). The interspinous ligaments are ossified, presenting as a slim ossified streak on the frontal radiograph (dagger sign; arrows). MRI, sagittal T1- weighted images of (c) the cervico-thoracic and (d) lumbar region, respectively, shows a general narrowing of the intervertebral discs with partial osseous fusion of the vertebral bodies, especially in the lumbar region (arrows). In addition a characteristic AS deformity with reduced lumbar lordosis and thoracic kyphosis.
Fig. 13 Pseudo-arthrosis-like changes in AS. (a) AP and (b) lateral radiograph showing vertebral fusion except at iv Th10/11. There is surrounding osteophyte formation at this iv space (arrows). Supplementary CT, (c) sagittal and (d) coronal 2D reconstruction, demonstrates lack of fusion of the vertebral bodies and apophyseal joints at this level (arrows). (e) 3D reconstruction clearly demonstrates the exuberant surrounding reactive osteophytes.
Fig. 14�Spinal fracture in AS. (a) AP and (b) lateral radiograph of the thoracic spine in a 64-year-old man with advanced AS and increasing back pain over 4 weeks. The lateral view demonstrates a slight malalignment at the anterior aspects of the vertebral bodies of Th9 and Th10, and the iv is irregularly narrowed on the AP view, all�suggesting fracture (arrows). CT, (c) sagittal and (d) coronal reconstruction, shows fracture through the iv space and the posterior structures (arrows). There is widening of the intervertebral space anteriorly in the supine position used for CT compared with the upright position used during radiography.
Axial psoriatic arthritis (PsA) occurs in approximately 50% of patients with peripheral PsA [31]. It differs radiographically from AS by the voluminous paravertebral ossifications and the occurrence of spinal changes without concomitant sacroiliitis in 10% of patients [32]. Axial PsA may be clinically silent [33], and involvement of the cervical spine is frequent (atlanto-axial or apophyseal joint changes). The cervical recognize may include atlanto-axial instability as seen in RA (Fig. 19), but the pathogenesis and thereby imaging findings are different. In PsA radiography and CT usually visualize new bone formation in the region of the dens. This is elicited by osseous inflammation (osteitis) and/or inflammation at ligament/ tendon attachments (enthesitis) detectable by MRI (Fig. 19). Osteitis is often a feature of spinal PsA and can occur together with paravertebral ossification/para- syndesmophytes and erosion of vertebral plates (Fig. 20). , and illustrated MR findings in PsA are based on personal observations and seem to reflect the radiographic changes encompassing a mixture of osteitis, enthesitis and erosion. Unfortunately, there is a lack of�systematic description of spinal changes in PsA by MRI. Some of the patients described under the term SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome may have PsA. SAPHO is a collective term often used for inflammatory disorders primarily presenting with osseous hyperostosis and sclerosis, and they are frequently associated with skin disorders. The most commonly affected site in SAPHO is the anterior chest followed by the spine [34]. The PsA changes shown in Fig. 20 are characterized by hyperostosis and sclerosis, both main features of SAPHO. However, this patient did not have anterior chest involvement.
Fig. 15 CT detection of costo-vertebral changes in AS. Axial CT slices showing erosive changes (a) and ankylosis of costo-vertebral joints (b), respectively (arrows).
Fig. 16 Activity changes in AS by MRI. Sagittal STIR of (a) the cervico-thoracic and (b) the lumbar spine of the patients shown in Fig. 10 obtained 3 years before the radiography. There are multiple high signal intensity areas corresponding to vertebral corners (white arrows). Additionally, osseous oedema of the costo-vertebral joints (a, black arrows) seen on the lateral sagittal slice of the thoracic spine. (c) Axial post-contrast T1FS of an inflamed costo-vertebral joint confirmed the presence of joint inflammation in the form of osseous enhancement in both the vertebra and the rib (arrows) in addition to joint erosion. (d) Midline sagittal post-contrast T1FS shows an�enhancing syndesmophyte. (e) Inflammatory changes at the apophy- seal joint in a 27-year-old man; sagittal STIR image of the lumbar region showing subchondral osseous oedema in the lower thoracic region (white arrows), and both osseous and soft tissue oedema corresponding to the lumbar apophyseal joints (black arrows). Note that the osseous oedema in the pedicle of Th12 extends to the region of the costo-vertebral joint. (f) Coronal post-contrast T1FS of the lumbar spine shows additional enhancement corresponding to the interspinous ligament between L2 and L3 (arrows).
Fig. 17 Chronic changes in AS by MRI. Sagittal T1 (a) the cervico-thoracic and (b) the lumbar spine of the patients shown in Fig. 10. There are multiple fatty marrow depositions at vertebral corners and also posteriorly in thoracic vertebral bodies (b, arrows). This was observed to have developed since the MRI performed 3 years previously (shown in Fig. 16 a-d) and corresponds to areas of previous inflammation.
In patients with enteropathic arthritis associated with Crohn�s disease or ulcerative colitis, the spine is often osteoporotic with various accompanying SpA features by radiography, mostly AS-like changes. However, by MRI there may be more pronounced inflammation in the posterior ligaments than seen in the other forms of SpA (Fig. 21).
Fig. 18 Psoriatic arthritis (PsA), paravertebral ossifications. (a) AP and (b) lateral radiograph of the lumbar spine in a 48-year-old man with PsA showing voluminous paravertebral new bone forma- tion (arrows) in addition to fusion of the second and third vertebral bodies. There was no concomitant sacroiliitis. (c) AP radiograph of the thoraco- lumbar junction in a female patient with axial PsA demon- strating coalescing paravertebral ossifications (arrows).
Fig. 19 Cervical PsA. (a) Lateral radiographs in the neutral position and (b) during flexion in a 61-year-old woman show atlanto-axial instability with a 4-mm distance between the anterior arc and the dens (white line). Additionally, ankylosis of the apophyseal joints (black arrows) and new bone formation anterior to the C4-7 vertebral bodies (white arrows). CT, (c) axial slice and coronal reconstruction of the dens area, demonstrates new bone formation in the atlanto-axial region (arrows); (d) coronal reconstruction of the lower cervical region shows voluminous new bone formation on the right side of the vertebral bodies (arrows). MRI, (e) sagittal STIR and (f) T1-weighted images, shows homogeneous osseous inflammation corresponding to the dens (arrows) with surrounding irregular oedema compatible with a mixture of osteitis and enthesitis. Note that the anterior new bone formation visualised by radiography is difficult to detect on MRI.
Fig. 20 Lumbar PsA. (a) AP and (b) lateral radiograph in a 50-year- old man show voluminous paravertebral ossifications anteriorly and at the right side of the third lumbar vertebra and adjacent iv spaces. MRI, (c) sagittal STIR, (d) T1 and (e) post-contrast T1-weighted images, demonstrates manifest osseous inflammation (osteitis) in the form of oedema and enhancement of the vertebral body, slight enhancement in the paravertebral new bone formation and erosion of the upper vertebral plate compatible with a mixture of osteitis, enthesitis and erosive changes.
Fig. 21 Enteropathic SpA. Sagittal STIR image of the lumbar spine in a 27-year-old man with ulcerative colitis demonstrates oedema corresponding to the interspinous ligaments (arrows) and spinous processes as signs of inflammation. There are only minimal activity changes corresponding to the vertebral bodies, located to the anterior vertebral corners.
Rheumatoid arthritis of the spine can cause neck pain, back pain, and/or radiating pain in the upper and lower extremities. In severe cases, RA can also lead to the degeneration of the spine, resulting in the compression or impingement of the spinal cord and/or the spinal nerve roots. As a chiropractor, we offer diagnostic imaging to help determine a patient’s health issue, in order to develop the best treatment program.
Dr. Alex Jimenez D.C., C.C.S.T.
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Conclusion
Radiography is still valuable in the diagnosis of spinal inflammatory disorders. It is necessary for visualizing instability and is superior to MRI for detecting syndesmophytes. However, MRI and CT can detect signs of spinal involvement before they can be visualized by radiography. MRI adds information about potential involvement of the spinal cord and nervous roots in addition to signs of disease activity and chronic changes such as fibrous pannus in RA and fatty marrow deposition, erosion and vertebral fusion in SpA. MRI is�therefore widely used to monitor inflammatory spinal diseases, especially during anti-TNF therapy.
Computed tomography is particularly valuable in the detection of fracture and minor osseous lesions as well as in the evaluation of pseudo-arthrosis. In conclusion, rheumatoid arthritis most commonly affects the structure and function of your hands, wrists, elbows, hips, knees, ankles and feet, however, people with this chronic inflammatory disease can experience back pain. Imaging the spine�in arthritis is fundamental to determine treatment. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topics: Acute Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
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Iizuka H, Sorimachi Y, Ara T, Nishinome M, Nakajima T, Iizuka Y et al (2008) Relationship between the morphology of the atlanto-occipital joint and the radiographic results in patients with atlanto-axial subluxation due to rheumatoid arthritis. Eur Spine J 17(6):826�830 7. Narvaez JA, Narvaez J, Serrallonga M, De Lama E, de AM, Mast R et al (2008) Cervical spine involvement in rheumatoid arthritis: correlation between neurological manifestations and magnetic resonance imaging findings. Rheumatology (Oxford) 47 (12):1814�1819 8. Dougados M, van der Linden S, Juhlin R, Huitfeldt B, Amor B, Calin A et al (1991) The European Spondylarthropathy Study Group preliminary criteria for the classification of spondylarthr- opathy. Arthritis Rheum 34:1218�1227 9. Rudwaleit M, van der Heijde D, Landewe R, Listing J, Akkoc N, Brandt J et al (2009) The Development of Assessment of SpondyloArthritis international Society (ASAS) classification criteria for axial spondyloarthritis (Part II): validation and final selection. Ann Rheum Dis 68(6):777�783 10. Sieper J, Rudwaleit M, Khan MA, Braun J (2006) Concepts and epidemiology of spondyloarthritis. Best Pract Res Clin Rheumatol 20(3):401�417 11. van der Linden S, Valkenburg HA, Cats A (1984) Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum 27:361� 268 12. Maksymowych WP, Chiowchanwisawakit P, Clare T, Pedersen SJ, Ostergaard M, Lambert RG (2009) Inflammatory lesions of the spine on magnetic resonance imaging predict the development of new syndesmophytes in ankylosing spondylitis: evidence of a relationship between inflammation and new bone formation. Arthritis Rheum 60(1):93�102 13. Sieper J, Rudwaleit M, Baraliakos X, Brandt J, Braun J, Burgos- Vargas R et al (2009) The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis. Ann Rheum Dis 68(Suppl 2:ii):1�44 14. Park WM, Spencer DG, McCall IW, Ward J, Buchanan WW, Stephens WH (1981) The detection of spinal pseudarthrosis in ankylosing spondylitis. Br J Radiol 54(642):467�472 15. Madsen KB, Jurik AG (2009) MRI grading method for active and chronic spinal changes in spondyloarthritis. Clin Radiol 65:6�14 16. Feldtkeller E, Vosse D, Geusens P, van der Linden S (2006) Prevalence and annual incidence of vertebral fractures in patients with ankylosing spondylitis. Rheumatol Int 26(3):234�239 17. Thomsen AH, Uhreholt L, Jurik AG, Vesterby A (2010) Traumatic death in ankylosing spondylitis�a case report. J Forensic Sci 55(4):1126�1129 18. Bennett AN, Rehman A, Hensor EM, Marzo-Ortega H, Emery P, McGonagle D (2009) Evaluation of the diagnostic utility of spinal magnetic resonance imaging in axial spondylarthritis. Arthritis Rheum 60(5):1331�1341 19. Appel H, Loddenkemper C, Grozdanovic Z, Ebhardt H, Dreimann M, Hempfing A et al (2006) Correlation of histopathological findings and magnetic resonance imaging in the spine of patients with ankylosing spondylitis. Arthritis Res Ther 8(5):R143 20. Braun J, Baraliakos X, Golder W, Hermann KG, Listing J, Brandt J et al (2004) Analysing chronic spinal changes in ankylosing spondylitis: a systematic comparison of conventional x rays with magnetic resonance imaging using established and new scoring systems. Ann Rheum Dis 63(9):1046�1055 21. Baraliakos X, Listing J, Brandt J, Haibel H, Rudwaleit M, Sieper J et al (2007) Radiographic progression in patients with ankylosing spondylitis after 4 years of treatment with the anti- TNF-alpha antibody infliximab. Rheumatology (Oxford) 46 (9):1450�1453 22. Lambert RG, Salonen D, Rahman P, Inman RD, Wong RL, Einstein SG et al (2007) Adalimumab significantly reduces both spinal and sacroiliac joint inflammation in patients with ankylos- ing spondylitis: a multicenter, randomized, double-blind, placebo- controlled study. Arthritis Rheum 56(12):4005�4014 23. Baraliakos X, Landewe R, Hermann KG, Listing J, Golder W, Brandt J et al (2005) Inflammation in ankylosing spondylitis: a systematic description of the extent and frequency of acute spinal�changes using magnetic resonance imaging. Ann Rheum Dis 64 (5):730�734 24. Khanna M, Keightley A (2005) MRI of the axial skeleton manifestations of ankylosing spondylitis. Clin Radiol 60(1):135�136 25. Levine DS, Forbat SM, Saifuddin A (2004) MRI of the axial skeletal manifestations of ankylosing spondylitis. Clin Radiol 59 (5):400�413 26. Baraliakos X, Hermann KG, Landewe R, Listing J, Golder W, Brandt J et al (2005) Assessment of acute spinal inflammation in patients with ankylosing spondylitis by magnetic resonance imaging: a comparison between contrast enhanced T1 and short tau inversion recovery (STIR) sequences. Ann Rheum Dis 64 (8):1141�1144 27. Gaspersic N, Sersa I, Jevtic V, Tomsic M, Praprotnik S (2008) Monitoring ankylosing spondylitis therapy by dynamic contrast- enhanced and diffusion-weighted magnetic resonance imaging. Skeletal Radiol 37(2):123�131 28. Weber U, Maksymowych WP, Jurik AG, Pfirrmann CW, Rufibach K, Kissling RO et al (2009) Validation of whole-body against conventional magnetic resonance imaging for scoring acute inflammatory lesions in the sacroiliac joints of patients with spondylarthritis. Arthritis Rheum 61(7):893�899 29. Weber U, Hodler J, Jurik AG, Pfirrmann CW, Rufibach K, Kissling RO et al (2010) Assessment of active spinal inflamma- tory changes in patients with axial spondyloarthritis: validation of whole body MRI against conventional MRI. Ann Rheum Dis 69 (4):648�653 30. Helliwell PS, Hickling P, Wright V (1998) Do the radiological changes of classic ankylosing spondylitis differ from the changes found in the spondylitis associated with inflammatory bowel disease, psoriasis, and reactive arthritis? Ann Rheum Dis 57(3):135�140 31. Chandran V, Barrett J, Schentag CT, Farewell VT, Gladman DD (2009) Axial psoriatic arthritis: update on a longterm prospective study. J Rheumatol 36(12):2744�2750 32. Lubrano E, Marchesoni A, Olivieri I, D’Angelo S, Spadaro A, Parsons WJ et al (2009) Psoriatic arthritis spondylitis radiology index: a modified index for radiologic assessment of axial involvement in psoriatic arthritis. J Rheumatol 36(5):1006�1011 33. Hanly JG, Russell ML, Gladman DD (1988) Psoriatic spondy- loarthropathy: a long term prospective study. Ann Rheum Dis 47 (5):386�393 34. Takigawa T, Tanaka M, Nakanishi K, Misawa H, Sugimoto Y, Takahata T et al (2008) SAPHO syndrome associated spondylitis. Eur Spine J 17(10):1391�1397
Spinal trauma consists of spine fractures, or spinal fractures, and spinal cord injuries. Approximately 12,000 spinal trauma cases are reported in the United States every year. While the most prevalent causes of spinal cord injuries and spine fractures are automobile accidents and falls, spinal trauma can also be attributed to assault, sports injuries, and work-related accidents. Diagnosis of spinal trauma includes imaging and assessment of nerve function, such as reflex, motor, and sensation. The following article discusses the role of emergency radiology in spinal trauma. Chiropractic care can help provide diagnostic evaluations for spinal trauma.
Abstract
Spinal trauma is very frequent injury with different severity and prognosis varying from asymptomatic condition to temporary neurological dysfunction, focal deficit or fatal event. The major causes of spinal trauma are high- and low- energy fall, traffic accident, sport and blunt impact. The radiologist has a role of great responsibility to establish the presence or absence of lesions, to define the characteristics, to assess the prognostic influence and therefore treatment. Imaging has an important role in the management of spinal trauma. The aim of this paper was to describe: incidence and type of vertebral fracture; imaging indication and guidelines for cervical trauma; imaging indication and guidelines for thoracolumbar trauma; multidetector CT indication for trauma spine; MRI indication and protocol for trauma spine.
Introduction
The trauma of the spine weighs heavily on the budget of social and economic development of our society. In the USA, 15�40 cases per million populations with 12,000 cases of paraplegia every year, 4000 deaths before admission and 1000 deaths during hospitalization are estimated. The young adult population is the most frequently involved in road accidents, followed by those at home and at work, with a prevalence of falls from high and sports injuries.1
Imaging has an important role in the management of spinal trauma. Quick and proper management of the patients with trauma, from diagnosis to therapy, can mean reduction of the neurological damage of vital importance for the future of the patient. Radiologists have a role of great responsibility to establish the presence or absence of lesions, defining the characteristics, assessing the prognostic influence and therefore treatment.
The aim of this paper was to describe:
incidence and type of vertebral fracture
imaging indication and guidelines for cervical trauma
imaging indication and guidelines for thoracolumbar trauma
multidetector CT (MDCT) pattern for trauma spine
MRI pattern for trauma spine.
Spinal trauma, including spine fractures and spinal cord injuries, represent about 3 percent to 6 percent of all skeletal injuries. Diagnostic assessments are fundamental towards the complex diagnosis of spinal trauma. While plain radiography is the initial diagnostic modality used for spine fractures and/or spinal cord injuries, CT scans and MRI can also help with diagnosis. As a chiropractic care office, we can offer diagnostic assessments, such as X-rays, to help determine the best treatment.
Dr. Alex Jimenez D.C., C.C.S.T.
Vertebral Fracture Management and Imaging Indication and Evaluation
The rationale of imaging in spinal trauma is:
To diagnose the traumatic abnormality and characterize the type of injury.
To estimate the severity, potential spinal instability or damaged stability with or without neurological lesion associated, in order to avoid neurological worsening with medical legal issue.
To evaluate the state of the spinal cord and surrounding structures (MR is the gold standard technique).
Clinical evaluation involving different specialities�emergency medicine, trauma surgery, orthopaedics, neurosurgery and radiology or neuroradiology�and trauma information is the most important key point in order to decide when and which type of imaging technique is indicated.2
A common question in patients with spine trauma is: is there still a role for plain-film X-ray compared with CT?
In order to clarify when and what is more appropriate for spinal trauma, different guidelines were published distinguishing cervical and thoracolumbar level.
Cervical Spinal Trauma: Standard X-Ray and Multidetector CT Indication
For cervical level, controversy persists regarding the most efficient and effective method between cervical standard X-ray with three film projections (anteroposterior and lateral view plus open-mouth odontoid view) and MDCT.
X-ray is generally reserved for evaluating patients suspected of cervical spine injury and those with injuries of the thoracic and lumbar areas where suspicion of injury is low. Despite the absence of a randomized controlled trial and thanks to the high quality and performance of�MDCT and its post-processing (multiplanar reconstruction and three-dimensional volume rendering), the superiority of cervical CT (CCT) compared with cervical standard X-ray for the detection of clinically significant cervical spine injury is well demonstrated.
Figure 1. (a�l). A 20-year-old male involved in a motorbike accident. The multidetector CT with multiplanar reformatted and three- dimensional volume-rendering reconstructions (a�d) showed traumatic fracture of C6 with traumatic posterior spondylolisthesis grade III with spinal cord compression. The MRI (e�h) confirmed the traumatic fracture of C6 with traumatic posterior spondylolisthesis grade III with severe spinal cord compression. The post-surgical treatment MRI control (i�l) showed the sagittal alignment of cervical level and severe hyperintensity signal alteration of the spinal cord from C3 to T1.
In order to reduce the patient radiation exposure, it is important to determine and to select patients who need imaging and those who do not, through the clinical evaluation and probability of cervical spine injury, using only MDCT for the appropriate patient as is more cost-effective screening.3
First of all, it is necessary to distinguish the type of trauma:
minor trauma (stable patient, mentally alert, not under the influence of alcohol or other drugs and who has no history or physical findings suggesting a neck injury)
major and severe trauma (multitrauma, unstable patient with a simple temporary neurological dysfunction, with focal neurological deficit or with a history or mechanism of injury sufficient to have exceeded the physiologic range of motion).
Second, it is important to establish if trauma risk factors are presents, such as:
violence of trauma: high-energy fall (high risk) or low-energy fall (low risk)
age of the patient: <5years old, >65 years old�
associated lesions: head, chest, abdomen (multitrauma) etc.
clinical signs: Glasgow Coma Scale (GCS), neurological deficit, vertebral deformation.
Combining these elements, patients can be divided into �low risk� and �high risk� for cervical injury.
The first group consists of patients who are awake (GCS 15), alert, cooperative and non-intoxicated without any distract- ing injury.
The second group consists of unconscious, sedated, intoxicated or non-cooperative patients or those with a distracting injury or an altered mental state (GCS ,15) with a 5% chance of cervical spine injuries.3,4
CCT has a wider indication than X-ray for patients at very high risk of cervical spine injury (major trauma or multitrauma). No evidence suggests CCT instead of X-ray for a patient who is at low risk for cervical spine injury.5
Figure 2. (a�g). A 30-year-old male involved in a motorbike accident. The multidetector CT with multiplanar reformatted and three-dimensional volume-rendering reconstructions (a�d) showed traumatic burst fracture of L1 (A2-type Magerl class) with posterior bone fragment dislocation into spinal canal. The MRI (e�g) confirmed the burst fracture of L1 with moderate spinal cord compression.
Figure 3. (a�d) A 50-year-old male involved in a motorbike accident with acute spinal cord compression symptoms on anticoagulation treatment. The MRI showed an acute haemorrhagic lesion at the C2�C4 posterior epidural space, hypointense on sagittal T1 weighted (a) and hyperintense on T2 weighted (b) with spinal cord compression and dislocation on axial T2* (c) and T2 weighted (d).
In 2000, the National Emergency X-Radiography Utilization (NEXUS) study, analysing 34,069 patients, established low-risk criteria to identify patients with a low probability of cervical spine injury, who consequently needed no cervical spine�imaging. To meet the NEXUS criteria, a patient must have the following conditions:
no tenderness at the posterior midline of the cervical spine
no focal neurologic deficit
normal level of alertness
no evidence of intoxication
no clinically apparent painful injury that might distract the patient from the pain of a cervical spine injury.6
If all of these roles are present, the patient does not need to undergo X-ray because he has a low possibility of having a cervical spine injury with a sensitivity of 99% and a specificity of 12.9%.7
In 2001, the Canadian C-spine rule (CCSR) study developed a second decision rule using the risk factor of the trauma: three high-risk criteria (age $ 65 years, dangerous mechanism and paraesthesias in extremities), five low-risk criteria (simple rear-end motor vehicle collision, sitting position in emergency department, ambulatory at any time, delayed onset of neck pain and absence of midline cervical spine tenderness) and the ability of the patient to actively rotate his or her neck to determine the need for cervical spine radiography. In practice, if one of these risk factors is present, the patient needs to undergo imaging evaluation. On the other hand, if the risk factors are not present, the use of the NEXUS criteria plus a functional evaluation of the cervical spine is needed (left and right cervical spine rotation .45�); if this functional evaluation is possible, imaging is unnecessary. If an incomplete cervical movement is present, then the patient needs to be checked with imaging. The results showed the criteria to have a sensitivity of up to 100% and a specificity of up to 42.5%.8
Applying these criteria, before cervical spine imaging, the authors report a decrease of about 23.9% in the number of negative CCT, and applying a more liberal NEXUS criteria including the presence or absence of pain, limited range of motion or posterolateral cervical spine tenderness, they report a decrease of up to 20.2% in the number of negative studies.2
If these clinical criteria cannot be applied, CCT must be performed.
Major and severe traumas request a direct CCT screening, especially because there could be associated lesions, according to the high-risk criteria developed by Blackmore and Hanson to identify patients with trauma at high risk of c-spine injury who would benefit from CT scanning as the primary radiological investigation9 Figure 1.
Thoracolumbar Spinal Trauma: Standard X-Ray and Multidetector CT Indication
For thoracolumbar level, MDCT is a better examination for depicting spine fractures than conventional radiography. It has wider indication in the diagnosis of patients with thoracolumbar trauma for bone evaluation. It is faster than X-ray, more sensitive, thanks to multiplanar reformatted or volume-rendering reconstruction detecting small cortical fracture, and the sagittal alignment can be evaluated with a wide segment evaluation.10
It can replace conventional radiography and can be performed alone in patients who have sustained severe trauma.10
In fact, thoracolumbar spinal injuries can be detected during visceral organ-targeted CT protocol for blunt traumatic injury.
Figure 4. A 55-year-old female involved in a car accident with acute left cervical brachialgia. The sagittal T2 weighted (a) and axial T2 weighted (b) MRI showed a post-traumatic posterolateral herniated disc with spinal cord compression and soft hyper signal alteration on the C3�C4 spinal cord.
Thanks to multidetector technology, images reconstructed using a soft algorithm and wide-display field of view that covers the entire abdomen using a visceral organ-targeted protocol with 1.5-mm collimation are sufficient for the evaluation of spine fractures in patients with trauma, given that multiplanar reformatted images are provided without performing new CT study and without increasing radiation dose11 Figure 2.
With MDCT there is no information about spinal cord status or ligament lesion or acute epidural haematoma; it can only evaluate bone status. Spinal cord injury is suspected only by clinical data.
CCT is strictly recommended in patients affected by blunt cerebrovascular injuries. Both lesions can be strictly correlated and generally; contrast medium administration to exclude hemorrhagic brain lesion and cervical fracture is not needed.10
Magnetic resonance imaging, or MRI, is a medical diagnostic assessment technique utilized in radiology to create pictures of the anatomy and the physiological processes of the human body. Alongside radiography and CT scans, MRI can be helpful in the diagnosis of spinal trauma, including spine fractures and spinal cord injuries. Magnetic resonance imaging may not be necessary for all cases of spinal trauma. However, it could provide detailed information on the other soft tissues of the spine.�
Dr. Alex Jimenez D.C., C.C.S.T.
Spinal Trauma and MRI
Even if MDCT is the first imaging modality in a patient with trauma, MRI is essential for the soft assessment of the ligament, muscle or spinal cord injury, spinal cord, disc, ligaments and neural elements, especially using T2 weighted sequences with fat suppression or T2 short tau inversion recovery (STIR) sequence.12 MRI is also used to classify burst fracture, obtaining information about the status of the posterior ligamentous complex, a critical determinant of surgical indication even if the diagnosis of ligament injuries remains complex, and its grade is also underestimated using high-field MRI.13
Figure 5. A 65-year-old female involved in domestic trauma with spinal cord symptoms. The sagittal T1 weighted (a) and T2 weighted (b) MRI showed a traumatic T12�L1 spinal cord contusion hypointense on T1 weighted and hyperintense on T2 weighted.
In the management of patients with polytrauma, MDCT total-body scan is necessary in an emergency condition, and�MRI whole-spine indication is secondary to the clinical status of the patient: spinal cord compression syndrome Figure 3�5�MRI protocols recommended for patients affected by spinal injury and trauma are the following:13,14
Sagittal T1 weighted, T2 weighted and STIR sequence for the�bone marrow and spinal cord injury or spinal cord compression evaluation owing to epidural haematoma or traumatic herniated disc
Sagittal gradient echo T2* sequence for haemorrhage evaluation of the spinal cord or into the epidural�subdural space
Sagittal diffusion-weighted imaging helpful when evaluating spinal cord injury, differentiating cytotoxic from vasogenic�oedema, assisting in detecting intramedullary haemorrhage. It can help to evaluate the degree of compressed spinal cord.
Axial T1 weighted and T2 weighted sequence for the right localization of the injury. Recently, for patients affected by acute blunt trauma and cervical spinal cord injury, the axial T2 weighted sequence has been shown to be important for trauma-predicting outcomes. On axial T2 weighted imaging, five patterns of intramedullary spinal cord signal alteration can be distinguished at the injury�s epicentre. Ordinal values ranging from 0 to 4 can be assigned to these patterns as Brain�and Spinal Injury Center scores, which encompassed the spectrum of spinal cord injury severity correlating with neurological symptoms and MRI axial T2 weighted imaging. This score improves on current MRI-based prognostic descriptions for spinal cord injury by reflecting functionally and anatomically significant patterns of intramedullary T2 signal abnormality in the axial plane.15
Figure 6. A 20-year-old female involved in domestic trauma with back pain resistance to medical therapy. The standard antero- posterior�laterolateral X-ray (a) showed no vertebral fractures. The MRI showed a bone marrow alteration at lumbar vertebral body hyperintense on T2 weighted (T2W) (a), hypointense on T1 weighted (T1W) (b) and short tau inversion recovery (STIR) (c).
MRI has also an important role in case of discordance between clinical status and CT imaging. In the absence of vertebral fracture, patients can suffer from back pain resistant to medical therapy owing to bone marrow traumatic oedema that can be detected only using STIR sequence on MRI Figure 6.
In spinal cord injury without radiologic abnormalities (SCI- WORA), MRI is the only imaging modality that can detect intramedullary or extramedullary pathologies or show the absence of neuroimaging abnormalities.16 SCIWORA refers to spinal injuries, typically located in the cervical region, in the absence of identifiable bony or ligamentous injury on complete, technically adequate, plain radiographs or CT. SCIWORA should be suspected in patients subjected to blunt trauma who report early or transient symptoms of neurologic deficit or who have existing findings upon initial assessment.17
Vertebral Fracture Type and Classification
The rationale of imaging is to distinguish the vertebral fracture type into two groups:
� vertebral compression fracture as vertebral body fracture compressing the anterior cortex, sparing the middle posterior columns associated or not with kyphosis � burst fracture as comminuted fracture of the vertebral body extending through both superior and inferior endplates with kyphosis or posterior displacement of the bone into the canal. and to distinguish which type of treatment the patient needs; by imaging, it is possible to classify fractures into stable or�unstable fracture, giving indication to conservative or surgical therapy.
Figure 7. (a�f) A 77-year-old female involved in domestic trauma with back pain resistance to medical therapy. The multidetector CT (a) showed no vertebral fractures. The MRI showed a Magerl A1 fracture with bone marrow oedema at T12�L1 vertebral body hypointense on T1 weighted (b), hyperintense on T2 weighted (c) and short tau inversion recovery (d) treated by vertebroplasty (e�f).
Figure 8. (a�d) A 47-year-old male involved in a motorbike accident with back pain resistance to medical therapy. The MRI showed a Magerl A1 fracture with bone marrow oedema at T12 vertebral body hypointense on T1 weighted (a) hyperintense on T2 weighted (b) and short tau inversion recovery (c) treated by assisted-technique vertebroplasty�vertebral body stenting technique (d).
Using MDCT and MRI, thanks to morphology and injury distribution, various classification systems have been used for identifying those injuries that require surgical intervention, distinguishing among stable and unstable fractures and surgical and non-surgical fractures.1
Denis proposed the �three-column concept�, dividing the spinal segment into three parts: anterior, middle and posterior columns. The anterior column comprises the anterior longitudinal ligament and anterior half of the vertebral body; the middle column comprises the posterior half of the vertebral body and posterior longitudinal ligament; and the posterior column comprises the pedicles, facet joints and supraspinous ligaments. Each column has different contributions to stability, and their damages may affect stability differently. Generally, if two or more of these columns are damaged, the spine becomes unstable.18
Magerl divided the vertebral compression fracture (VCF) into three main categories according to trauma force: (a) compression injury, (b) distraction injury and (c) rotation injury. Type A has conservative or non-surgical mini-invasive treatment indication.19
The thoracolumbar injury classification and severity score (TLICS) system assigns numerical values to each injury based on the categories of morphology of injury, integrity of the posterior ligament and neurological involvement. Stable injury patterns (TLICS,4) may be treated non-operatively with�brace immobilization. Unstable injury patterns (TLICS.4) may be treated operatively with the principles of deformity correction, neurological decompression if necessary and spinal stabilization.20
The Aebi classification is based on three major groups: A = isolated anterior column injuries by axial compression, B = disruption of the posterior ligament complex by distraction posteriorly and C = corresponding to group B but with rotation. There is an increasing severity from A to C, and within each group, the severity usually increases within the subgroups from 1 to 3. All these pathomorphologies are supported by the mechanism of injury, which is responsible for the extent of the injury. The type of injury with its groups and subgroups is able to suggest the treatment modality.21
Thoracolumbar Fracture and Mini-Invasive Vertebral Augmentation Procedure: Imaging Target
Recently, different mini-invasive procedures called assisted- technique vertebroplasty (balloon kyphoplasty KP or kyphoplasty-like techniques) have been developed in order to obtain pain relief and kyphosis correction as alternative treatment for non-surgical but symptomatic vertebral fracture.
The rationale of these techniques is to combine the analgesic and vertebral consolidation effect of vertebroplasty with the restoration of the physiological height of the collapsed vertebral body, reducing the kyphotic deformity of the vertebral body, delivering cement into the fractured vertebral body with a vertebral stabilization effect compared with conservative therapy (bed rest and medical therapy).22
From interventional point of view, imaging has an important role for treatment indication together with clinical evaluation. Both MDCT and MRI are recommended Figure 7 and 8.
In fact, MDCT has the advantage of diagnosing VCF with kyphosis deformity easily, while MRI with STIR sequence is useful to evaluate bone marrow oedema, an important sign of back pain.
Patients affected by vertebral fracture without bone marrow oedema on STIR sequence are not indicated for interventional procedure.
According to imaging, Magerl A1 classification fractures are the main indication of treatment.
However, the treatment must be performed within 2�3 weeks from trauma in order to avoid sclerotic bone response: the younger the fractures, the better the results and easier the treatment and vertebral augmentation effect. To exclude sclerotic bone reaction, CT is recommended.
Conclusion
The management of spinal trauma remains complex. MDCT has a wide indication for bone evaluation in patients affected by severe trauma or patients with high risk of spine injury. MRI has a major indication in the case of spinal cord injury and the absence of bone lesion. Diagnostic assessment of spinal trauma, including radiography, CT scans, and MRI are fundamental towards the diagnosis of spine fractures and spinal cord injury for treatment. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topics: Acute Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
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It is required to perform minimum 2-views orthogonal to each other:
1 AP (Anterior to Posterior) or PA (Posterior to Anterior)
2 Lateral
Supplemental views: Oblique views etc.
Skeletal radiographs typically use AP & lateral views
Chest radiographs and Scoliosis imaging in children will usually use the PA technique
Exceptions for PA chest views: patients unable to cooperate (severely ill or unconscious patients)
X-rays are a form of electromagnetic energy (EME) similar to light photons or other sources
X-rays are a form of man-made radiation
Ionizing effect of x-rays process of removal of atomic electrons from their orbits
Two basic types of ionizing radiation:
Particle (particulate) radiation produced by alpha & beta particles that are the result of radioactive decay of different materials
Electromagnetic Radiation (EMR) produced by x-rays or gamma rays called photons
The energy of EMR depends on its wavelength
Shorter wavelength corresponds to higher energy
The energy of EME is inversely related to its wavelength
X-ray Properties
No charge
Invisibility
Penetrability of most matters (esp. human tissues) depends on “Z” (atomic number)
Making compounds fluoresce and emit light
Travel at the speed of light
Ionization and biologic effect on living cells
The Imaging System
X-rays are produced by an imaging system ( x-ray tube, operator’s console, and high voltage generator)
X-ray tube composed of (-) charged cathode and (+) charged anode enclosed in the evacuated class envelope and housed in the protective coat of metal
A Cathode made up of filament wire embedded within the focusing cup to give electrostatic focus to electrons’ cloud
Filament wire of heat resistant thorium tungsten metal of high melting point (3400 C) that “boils off” electrons during thermionic emission
Focusing cup polished nickel (-) charged that�accommodated� the filament to electrostatically repulse the electrons and confines them to the focal spot of the anode disc where x-rays are produced
Anode (+) charged target for electrons to interact at the focal spot
Conducts electricity
Rotates to dissipating heat
Made of tungsten to resist heat
Anode has a high atomic number to produce x-rays of very high efficiency at the focal spot
There are 2-focal spots large and small, each corresponding to cathode’s filament size (small vs. large) that depends on the magnitude of current in the cathode dictated by a radiographic study of larger or smaller body parts
It is known as the dual focus principle
When Electrons are emitted from the cathode as the cloud, they slam into the Anode’s focal spot resulting in 3 man events
Production of heat (99% outcome)
Production of Bremsstrahlung (i.e., breaking radiation) x-rays that represent the majority of x-rays within the x-ray emission spectrum
Production of Characteristic x-rays very few in the emission spectrum
Newly formed x-rays at the anode are of different energies
Only need high energy or “hard” x-rays to perform the radiographic study
Before x-rays exiting the tube we need to remove weak or low energy photons, i.e., “harden the beam.”
Added tube filtration in the form of aluminum filters is used that removes at least 50% of the “unfiltered” beam thus minimizing the patient’s radiation dose and maximizing image quality
High Voltage Generator
X-ray production requires an uninterrupted flow of electrons to the anode
Regular electricity supplies AC power with sinusoidal currents of “peaks and drops.”
In the past, single-phase high voltage generators would convert AC power into a half, or full wave rectified supply with a measure in the thousands of volts delivered with a “voltage ripple” or peaks of high voltage. Therefore, a term kilo voltage peaks (kVp) was used
Modern generators provide “uninterrupted” flow of electrical potential to the x-ray tube eliminating “voltage ripples” thus referred to as kilovoltage kV without “peaks.”
When x-rays interact with the patient’s tissued 3 events will occur
X-rays will pass through without interaction and “expose” the image receptor
Photoelectric interaction/effect (PE) comparatively lower energy x-rays will be absorbed/attenuated by the tissues
Compton scatter x-rays are “bounced off” to form scatter, contributing no useful information to the film and lower image contrast while potentially giving unnecessary radiation dose to staff
The final image is the product of all three types of interactions known as
Differential absorption of x-ray photons – the result of photons’ absorption via PE, Compton scatter and x-rays passing through the patient
Compton scatter probability decreases with an increase in x-ray energy compared to PE effect
Compton effect probability does not depend on the atomic number (Z)
An increase of total mass density (thick vs. thin) will increase Compton and PE interaction
What cells in the body are considered most vulnerable and most resistant to radiation?
Cells that are rapidly dividing and not terminally differentiated, epithelial cells, etc. are more radiosensitive
Bone marrow cells (stem cells) & lymphocytes are very radiosensitive
Muscle & and nerve cells are terminally differentiated and are less sensitive to radiation
Aged (senescent cells) vs. immature fetal cells are more vulnerable to radiation
However, following low dose radiation in most healthy individual cells will be able to repair likely without any long-lasting changes
Pregnancy & radiation initial 6-7 weeks are the most vulnerable
Do not use routine (non-emergent) radiographic examinations in pregnancy
Apply 10-day rule establish that radiographs can only be obtained during the initial ten days from the onset of the last menstrual cycle
Radiographic imaging of children:
If clinically possible use non-ionizing forms of medical imaging (e.g., ultrasound)
Non-axial imaging studies that use x-ray photons:
Conventional radiography
Fluoroscopy
Mammography
Radiographic angiography (currently less often used)
Dental imaging
Cross-sectional imaging using x-ray photons: Computed Tomography
Indication and Contraindication for conventional radiographic imaging
Advantages of Radiography: widely available, inexpensive, low radiation burden, the first step in imaging investigation of most MSK complaints
Disadvantages: 2D imaging, relatively lower diagnostic yield during an examination of soft tissues, numerous artifacts, and dependence on correct radiographic factors selection, etc.
Indications:
Chest: initial assessment of lung/intrathoracic pathology. Potentially determines or obviates the need for chest CT scanning. Pre-surgical evaluation. Imaging of pediatric patients due to extremely low radiation dose.
Skeletal: to examine the bone structure and diagnose fractures, dislocation, infection, neoplasms, congenital bone dysplasia, and many forms of arthritis
Abdomen:�can assess acute abdomen, abdominal obstruction, free air or free fluid within the abdominal cavity, nephrolithiasis, evaluate placement of radiopaque tubes/lines, foreign bodies, monitor resolution of postsurgical ileus and others
TMJ dysfunction: The temporomandibular joints, TMJ, are the lower jaw hinges that sit on either side of the head in front of each ear. They are responsible for the lower jaw opening, closing, sliding, and rotating. The TMJs are the most body�s most complex joints. The typical person uses them more than 5,000 times a day by talking, laughing, yawning, chewing, eating, smiling, and swallowing.
What Is TMJ Dysfunction?
TMJ dysfunction occurs when one or both joints become inflamed or injured causing pain and immobility in the jaw area. Because these joints are used so often and tend to be far more mobile than most other joints in the body, they can be prone to pain.
It is important that both joints work together because if they don�t it could result in more pressure on one joint than the other and this could cause the pain and discomfort that is associated with TMJ dysfunction.
What Are The Symptoms Of TMJ Dysfunction?
There are many symptoms of TMJ dysfunction and they may vary depending on the patient, the extent of inflammation or injury, and the cause of the dysfunction. The symptoms may appear suddenly when there is injury to the joint, or they can gradually develop over a period of months or even years. They may be mild and barely noticeable or they can be severe and debilitating. The most common symptoms of TMJ dysfunction include:
Jaw pain
Jaw pain when moving the joint such as chewing or talking
Popping or clicking of the joint
Pain in the face or side of the neck
Locking jaw
Headaches
Toothache
Earache
Clogged or �stopped up� ear
Ringing in the ears (tinnitus)
TMJ dysfunction can significantly impact a person�s quality of life because the pain prevents them from doing many things they normally do, and often the jaw itself simply no longer functions as it should.
What Causes TMJ Dysfunction?
Damage to the joint is the primary cause of pain associated with TMJ dysfunction. This can be the result of trauma such as:
Subtle movements done repetitively can also cause TMJ dysfunction:
Grinding teeth
Holding a phone between the head and shoulder
Clenching teeth
Nail biting
Gum chewing (excessive)
Eating hard or tough foods
How Can Upper Neck Misalignment Cause TMJ Dysfunction?
When the upper neck sustains trauma such as whiplash it can cause a misalignment. This can also cause TMJ dysfunction in a couple of ways. It can cause one side to work harder or sustain more pressure than the other, or it can put excess pressure on the trigeminal nerve. This causes irritation and inflammation.
When left untreated, the condition can become severe. The misalignment keeps the joints from working as they should because opening and closing the jaw pinches the disc. This results in painful spasms in the shoulder and neck muscles when the patient does simple, everyday activities like talking, smiling, eating, or laughing.
Chiropractic For TMJ Dysfunction
Chiropractic can be a very effective treatment for TMJ dysfunction, especially if it is due to neck misalignment. A chiropractor will perform spinal adjustments in order to realign the spine and neck, bringing the body back into balance. This will allow the jaw to work as it should, minimizing rubbing or friction in the joint.
The patient may also be told to apply heat, massage, and do special exercises for TMJ dysfunction that will help the joints heal and help to minimize the pain.
This condition is not always easy to diagnose so it is wise to talk to your chiropractor and get a diagnosis before attempting any treatment or home remedies for TMJ. Regular chiropractic treatment can not only relieve the pain of TMJ and help to heal it, it can also help prevent it. Your chiropractor can be a great ally in this endeavor.
Injury Medical Clinic: Shoulder Pain Chiropractic Treatment
Muscle Relaxants? Nearly everyone, more than 80 percent of the world�s population, will experience back pain at some point in their lifetime. Just ask the 31 million Americans suffering from low back pain at any given time.
In fact, globally it is the leading cause of disability. It is the most common reason that people miss work and the second more common reason for doctor�s office visits. In the United States alone more than $50 billion is spent each year trying to relieve back pain, but even that figure is not complete, but only based on trackable, identifiable costs.
There have been studies published over the years that unequivocally show chiropractic as a viable and extremely effective treatment for back pain. Several of these studies plainly show that chiropractic is better than muscle relaxants.
Muscle Relaxants & Chiropractic Study
One study that is one of the most notable was conducted at Life University in Georgia. It has been cited in several journals and used as a catalyst for proving the efficacy of chiropractic treatment for back pain and its superiority to muscle relaxants.
Study Parameters
The study involved 192 subjects who had been experiencing lower back pain for a period of time ranging from two to six weeks. The subjects were separated into three groups:
Group One – Chiropractic adjustments combined with placebo medication
Group Two � Muscle relaxants combined with sham chiropractic adjustments
Group Three � Control Group � received both placebo medication and sham chiropractic adjustments
All groups were given the same length of care, four weeks, with an evaluation of progress at the two-week mark and the four-week mark. The pain was assessed using the Zung Self-Rating for Depression scale, the Oswestry Low Back Pain Disability Questionnaire, and the Visual Analog Scale (VAS). Upon admission into the study during the initial visit as well as at the two-week evaluation, Shober�s Test for Lumbar Flexibility was also administered.
The subjects in all three groups were also allowed to take acetaminophen for pain. This was an additional evaluative measure to assess the need for additional self-medication.
During the course of the study there was a two-week treatment period where the subjects in the chiropractic adjustment group received a total of seven adjustments. These adjustments were tailored to each patient�s specific needs and included pelvic adjustments, sacral (lower back), or lumbar and upper cervical (neck and back).
The sham treatments mimicked all aspects of an actual chiropractic adjustment including dialog, normal visit length, and procedures. However, no actual adjustments were performed.
Study Results
At the conclusion of the study, the subjects who received chiropractic treatment reported a significant decrease in pain and an increase in flexibility. Of the groups that did not receive chiropractic treatment there were no significant differences noted. There was a decrease in disability and depression across all three groups, indicating that muscle relaxants are effective in treating back pain, but overall chiropractic care is the more effective option for treating back pain and disability.
What Does This Mean For Patients With Back Pain?
Patients suffering from back pain can receive greater relief without the undesirable side effects of muscle relaxants by seeking chiropractic care. Patients who are using muscle relaxants to treat their back pain should talk to their chiropractor and doctor about incorporating chiropractic treatment into their patient care regimen. Patients experiencing back pain should pursue chiropractic care before resorting to more aggressive methods including muscle relaxants.
Chiropractic care is a safe, non-invasive treatment for back pain. It also facilitates healing, increases flexibility, and improves mobility. Patients who are looking for a healthy treatment option that focuses on overall wellness, Chiropractic could be the answer.
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