Back Clinic Imaging & Diagnostics Team. Dr. Alex Jimenez works with top-rated diagnosticians and imaging specialists. In our association, imaging specialists provide fast, courteous, and top-quality results. In collaboration with our offices, we provide the quality of service our patients’ mandate and deserve. Diagnostic Outpatient Imaging (DOI) is a state-of-the-art Radiology center in El Paso, TX. It is the only center of its kind in El Paso, owned and operated by a Radiologist.
This means when you come to DOI for a radiologic exam, every detail, from the design of the rooms, the choice of the equipment, the hand-picked technologists, and the software which runs the office, is carefully chosen or designed by the Radiologist and not by an accountant. Our market niche is one center of excellence. Our values related to patient care are: We believe in treating patients the way we would treat our family and we will do our best to ensure that you have a good experience at our clinic.
Spinal stenosis is when space somewhere along or within the spine begins to narrow, closing off the ability of normal/comfortable movement and nerve circulation. It can affect different areas, including the cervical/neck, lumbar/low back, and, less commonly, the thoracic/upper or mid-back regions causing tingling, numbness, cramping, pain, muscle weakness, or a combination in the back, leg/s, thighs, and buttocks. There can be various factors causing the stenosis; correct diagnosing is the first step, and where a spinal stenosis MRI comes in.
Spinal Stenosis MRI
Stenosis can be challenging to diagnose as it is more of a symptom/complication than a condition, often caused by herniated discs, bone spurs, a congenital condition, post-surgery, or after an infection. Magnetic resonance imaging/MRI is a common test used in diagnosis.
A healthcare professional, like a chiropractor, physical therapist, spine specialist, or physician, will begin with understanding symptoms and medical history.
A physical exam will be conducted to learn more about the location, duration, positions, or activities that decrease or worsen the symptoms.
Additional tests include muscle strength, gain analysis, and balance testing to help better understand where the pain is coming from.
To confirm a diagnosis, imaging will be required to see what is going on.
An MRI uses computer-generated imaging to produce images that show bone and soft tissues, like muscles, nerves, and tendons, and if they are compressed or irritated.
A healthcare professional and MRI technician will go over the safety requirements before the imaging.
Because the machine uses powerful magnets, there can be no metal on or in the body, like implanted prostheses or devices that include:
A different imaging test may be used if an individual cannot have an MRI like a CT scan.
An MRI can range from several minutes to an hour or longer, depending on how many positions are necessary to isolate the injured area and get a clear image. The test is painless, but sometimes individuals are asked to maintain a specific position that could be uncomfortable. The technician/s will ask if there is discomfort and offer any help to make the experience as easy as possible.
Not all cases of stenosis cause symptoms, but there are treatment options that a healthcare professional can recommend.
Conservative care is the first recommendation that includes chiropractic, decompression, traction, and physical therapy.
Treatment increases muscle strength, improves range of motion, improves posture and balance, decreases discomfort symptoms, and incorporates strategies to prevent and manage symptoms.
Prescription medications could be part of a larger treatment plan.
Surgery could become an option in more severe cases where conservative care is not working.
Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-. Diagnosis of lumbar spinal stenosis: an updated systematic review of the accuracy of diagnostic tests. 2013. Available from: www.ncbi.nlm.nih.gov/books/NBK142906/
Ghadimi M, Sapra A. Magnetic Resonance Imaging Contraindications. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: www.ncbi.nlm.nih.gov/books/NBK551669/
Gofur EM, Singh P. Anatomy, Back, Vertebral Canal Blood Supply. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: www.ncbi.nlm.nih.gov/books/NBK541083/
Lurie, Jon, and Christy Tomkins-Lane. “Management of lumbar spinal stenosis.” BMJ (Clinical research ed.) vol. 352 h6234. 4 Jan. 2016, doi:10.1136/bmj.h6234
Stuber, Kent, et al. “Chiropractic treatment of lumbar spinal stenosis: a review of the literature.” Journal of chiropractic medicine vol. 8,2 (2009): 77-85. doi:10.1016/j.jcm.2009.02.001
Chiropractors and spine specialists utilize spinal imaging through X-rays, MRIs, or CT scans to figure out what is causing back problems and pain. Imaging is common. Whether chiropractic or spinal surgery, they help immensely discover back issues and allow the individual to see what is happening. Types of cases include back pain that:
X-rays for back pain can be quite helpful. An X-ray is radiation-based and is used to examine the conditions of the bone structures. X-rays are optimal for bone tissue or tissues that are ossified or calcified. They work the best with hard tissues, specifically bones. Soft tissues like muscles, ligaments, or intravertebral discs do not present as well.
Individuals undergoing a back X-ray will be scanned by a machine that generates a beam. A receiver picks registers the beam after it passes through the body and generates an image. It takes around five minutes to complete but could be longer depending on the doctor’s number of images. X-rays are helpful for insurance purposes and rule out bone conditions like compression fractures and/or bone spurs. X-rays are ordered for specific reasons and are often part of a whole-body diagnostic study. This includes MRI and/or CT scan.
CT stands for computed tomography. It is a series of X-rays that are digitized into images using a computer. The advantage of a CT scan to standard X-rays is that it offers different views/angles of the body and can be in 3D. CT scans are most often used in trauma cases or individuals who have had surgery. They take around five minutes. For X-rays, individuals stand up or lay under the X-ray machine as it scans the body. A CT scan has the individual lie down in a circular donut-looking machine that scans while rotating during the imaging. Individuals are recommended to wear casual loose, comfortable clothing. Sometimes a dye, or intravenous contrast, is used to get the vascular tissues to stand out, generating clearer images.
MRI is short for magnetic resonance imaging. MRIs use magnets to generate images. MRI imaging is often used in individuals that have undergone surgery. They take longer, usually around 30 to 45 minutes. No metallic objects are allowed in the MRI. Patients are asked to remove items like belts, jewelry, etc. Contrast dye can be a part of an MRI. The machine is like a tunnel. This can become challenging for individuals that have claustrophobia. Consult with a doctor and find out how to get comfortable during the process.
Other Forms of Spinal Imaging
Other forms of imaging include:
CT navigation shows real-time CT scans during the procedure.
Fluoroscopy involves an X-ray beam that passes directly through the body that shows live, moving images.
Both of these types of spinal imaging are utilized during surgeries. For some cases, intraoperative imaging is used. This type of imaging uses high-tech robotics to help surgeons navigate through tight spaces during the procedure. This increases the surgeon’s accuracy and reduces the size of the incision.
Ultrasound can be used for spinal conditions. This is an imaging test that uses sound waves to generate images. However, the imaging tests which are used in spinal imaging are primarily X-rays and MRIs.
Talk with your doctor or chiropractor ahead of time to understand what to expect during the imaging process. They will let you know how to prepare and any special instructions before the appointment. Along with medical history and a physical examination, spinal imaging is an important part of the diagnostic process to find what is causing the pain and to develop the best treatment plan.
Short-term Effects of Coffee and Blood Pressure
The caffeine in coffee is a stimulant or substance that excites the body’s systems. When caffeine is ingested, individuals experience an increase in excitement, specifically in the cardiovascular system. This excitement causes the heart rate and blood pressure to rise and then lower back to a baseline level for healthy individuals. Coffee slightly increases short-term blood pressure. Moderate coffee consumption is safe for individuals that do not have pre-existing cardiovascular conditions.
Gartland classification grades minimally displaced subtle injuries treated with simple immobilization vs. posterior elbow dislocation treated operatively
A potential risk of ischemic compromise if care is delayed (Volkmann contracture)
The Radiological exam is crucial: sail sign & posterior fat pad sign with anterior humeral line failed to intersect mid/2/3 of Capitellum.
Incomplete pediatric Fx:
Most in <10 y.o. Greenstick, Torus, Plastic aka Bowing deformity
Typically heal well, treated conservatively with immobilization
Plastic deformity if >20-degrees requires closed reduction
Ping pong skull fracture may develop following trauma, forceps delivery and complications of birth trauma. May need to be assessed by the pediatric neurosurgeo.n
Salter-Harris types of physeal growth plate injuries
Type 1-slip. e.g., Slipped Capital Femoral Epiphysis. Typically no bone fracture noted
Type 2-M/C with good prognosis
Type 3- intra-articular, thus carries the risk of premature osteoarthritis and may require operative care d/t being unstable
Type 4- Fx through all regions about the physis. Unfavorable prognosis and limb shortening
Type 5- often no evidence of actual bone fracture. Poor prognosis d/t crush injury and vascular damage with limb shortening
Imaging evaluation is crucial
Non-Accidental Injury (NAI)in Children
There different forms of child abuse. Physical abuse may range from skin injuries to different MSK/systemic injuries affecting bones and soft tissues. Imaging is crucial and may identify definite signs alerting medical providers and informing child protection services and law enforcement agencies about physical abuse.
In an infant: �shaken baby syndrome� may present with CNS signs d/t tearing of immature bridging vein and subdural hematoma which can be fatal. Retinal hemorrhaging often a clue. Head CT is crucial.
MSK Radiological Red Flags:
1) major bone Fx in an un-ambulatory very young child (0-12 m.o.)
2) Posterior ribs Fx: naturally never occur d/t accidents. Most likely mechanisms: grabbing and squeezing a child or direct hit.
3) Multiple Fractures with different chronological healing rates, i.e., bone calluses indicating repeated physical trauma
4) Metaphyseal corner Fx aka Bucket handle Fx, often pathognomonic for NAI in children. Occurs when the affected extremity is held and violently twisted.
5) Spiral fracture of long bones in a young child is another example of NAI.
Other important clues of NAI. Inconsistent history provided by guardians/caregivers. No evidence of congenital/metabolic bone abnormalities like Osteogenesis Imperfecta or Rickets/osteomalacia etc.
N.B. When child�s guardians state a history that reports fall and accidents in the house, It is important to know that apparently most accidents/falls in the house are very rarely or unlikely result in major bone fractures.
Juvenile Idiopathic Arthritis (JIA)-considered M/C chronic disease of childhood. Clinical Dx: joint pain/swelling for 6-weeks or longer in a child <16-y.o. Different forms exist: Early Dx is crucial to prevent delayed complications
Most familiar forms of JIA:
1) Pauciarticular disease (40%)- m/c form of JIA. Girls are at greater risk. Presents as arthritis in <4 joints: knees, ankles, wrist. Elbow. This type shows high association with ocular involvement as iridocyclitis (25%) that may potentially lead to blindness. Labs: RF-ve, ANA positive.
2) Polyarticular disease (25%): RF-ve. Girls are at greater risk. Affects small and large joints often affect Cervical spine
3) Systemic form of JIA (20%): often presents with acute systemic manifestation as spiking fevers, arthralgias, myalgias, lymphadeno[pathy, hepatosplenomegaly, polyserositis (pericardial/pleural effusion). Important Dx features characteristic evanescent salmon pink rash on the extremities and trunk. The Systemic form has a distinct lack of ocular involvement. Joints typically shoe no erosions compared to other types. Thus joint destruction is not typically seen
Imaging in JIA
Joint effusion bone overgrowth squaring of patella cartilage/bone erosion superimposed DJD
Fingers and long bones early physeal closure/limb shortening
Rad DDx knee/ankle: Hemophilic arthropathy Rx: DMARD.
Osteosarcoma (OSA) & Ewing�s sarcoma (ES) are 1 st and 2nd M/C primary malignant bone neoplasms of childhood (peak at 10-20 y.o.) Clinically: bone pain, change in activity, early metastasis especially pulmonary mets may occur. Poor prognosis
Ewing�s may present with bone pain, fever and elevated ESR/CRP mimicking infection. Early Dx with imaging and staging are crucial.
Imaging of OSA & ES: x-ray, followed by MRI, chest CT, PET/CT. On x-rays: OSA may affect any bone but most present as aggressive bone forming neoplasms about the knee (50% cases) especially as osteoid forming an aggressive lesion in the metaphysis with speculated/sunburst periostitis & Codman triangle. Marked soft tissue invasion.
ES may present in the shaft and show very early soft tissue spread. MRI is crucial to reveal the extent of bone and ST invasion, MRI required for surgical planning
OSA & ES Rx: A combination of surgery, radiation, chemo. Limb salvage techniques are performed in some cases. Poor prognosis if detected late.
Imaging of Ewing�s sarcoma
Permeating bone distraction
Early and extensive soft tissue invasion
Aggressive periosteal reaction with laminated (onion skin) response
Saucerisation of cortical bone (orange arrow)
A Lesion is typically diaphyseal with some metaphyseal extension
Known as Round cell tumor along with Multiple Myeloma and Lymphoma
Common Childhood Malignancies
Neuroblastoma (NBL) M/C malignancy of infancy. Derives from neural crest cells aka PNET tumors (e.g., sympathetic ganglia). Most occur in children <24-months. Some show good prognosis but >50% cases present with advanced disease. 70-80% at age 18-months or older present with advanced metastasis. NBL may develop in the adrenal medulla, sympathetic ganglia and other location. Presents as an abdominal mass, vomiting. >50% presents with bone pain d/t metastasis. Clinically: physical exam, labs, imaging: chest and abd x-rays, CT abdomen and chest is crucial to Dx. MRI may help. NBL may metastasize to the skull and infiltrate sutures with a characteristic presentation as pathological sutural diastasis.
Acute Lymphoblastic Leukemia is the m/c malignancy of childhood. Pathology: leukemic cell infiltration of bone marrow leading to bone pain and replacement of other normal marrow cells with anemia, thrombocytopenia, neutropenia and associated complications. Leukemic cells may infiltrate other sites including CNS, spleen, bone and other regions. Dx: CBC, serum lactate dehydrogenase levels, Bone marrow aspiration biopsy is the key. Imaging may help but not essential to diagnosis. On radiography, leukemic infiltration of the bone may typically appear as radiolucent bands along the physeal growth plate. Rx: chemotherapy and treating complications
Medulloblastoma: M/C malignant CNS neoplasm in children
Majority develop before 10-y.o.
M/C location: cerebellum and posterior fossa
Histologically represents a PNET type tumor not a glioma as was originally thought
MBL, as well as Ependymoma and CNS lymphoma, may lead to drop metastasis via CSF and additionally represent a unique that unlike other CNS tumors demonstrate metastatic spread outside CNS, m/c to the bone
50% of MBL may be fully resectable
If Dx and treatment begin before metastasis, 5- year survival is 80%
Imaging is crucial: CT scanning may be used but the imaging modality of choice is MRI that will additionally provide a more superior evaluation of the entire neuraxis for metastasis.
MBL typically appears as heterogenous hypo, iso and hyperintense lesion on T1, T2 and FLAIR scans (top images) if compare to surrounding brain tissue. Often compressing 4th ventricle with obstructive hydrocephalus. The tumor typically shows contrast enhancement on T1+C gad (bottom left image). Drop metastasis from MBL with T1+C enhancing lesion in the cord
Important Pediatric Infections
In the neonate/infant <1month: fever >100.4 (38C) may indicate bacterial and some viral infection. Strep B, Listeria, E. Coli may lead to sepsis, meningitis. Approach: chest x-ray, lumbar puncture with culture, blood culture, CBC, urinalysis.
In young children, Hemophilus influenza type B (HIB) may lead to Epiglottitis a rare but serious complication. The current vaccine helps to reduce the number of cases of Epiglottitis and other HIB related illnesses.
Parainfluenza or RSV virus may lead to Croup or acute Laryngotracheobronchitis.
Epiglottitis and Croup are Dx clinically but AP and lateral soft tissue neck x-rays are very helpful
Epiglottitis presents with a characteristic �thumb sign� that is consistent with thickened epiglottis d/t epiglottic edema. This can be a life-threatening emergency compromising airways (top left)
Croup may show a �steeple sign� or �wine bottle sign� with distended hypopharynx as acute narrowing of subglottic airway on AP and lateral neck soft tissue x-ray (top right)
Respiratory Syncytia Virus (RSV) and influenza may lead to viral pneumonia potentially with life-threatening complications in the immunocompromised, very young and children with comorbidities. CXR is crucial (middle left)
Streptococcal pharyngitis with GABHS infection may lead to some acute or delayed complications (e.g., Rheumatic fever)
Peritonsillar abscess (above middle right) may develop in some cases and be complicated by spreading along soft tissue planes in the neck potentially leading to spread into sublingual/submandibular spaces (Ludwig Angina) when airways need to be controlled d/t base of tongue edema
Development of a retropharyngeal abscess may potentially lead to spread of the infection through freely communicating neck fascia resulting in necrotizing mediastinitis, Lemmier syndrome and invasion of carotid spaces (all are potentially life-threatening complications)
Griesel syndrome- (above bottom left) rare complication of regional tonsillar/pharyngeal oral infections that can spread to prevertebral space leading to C1-2 ligaments laxity and instability
Other important infections in children are typical bacterial (Pneumococcal) pneumonia, Urinary tract infection and Acute Pyelonephritis (especially in girls) and Meningococcal Meningitis
Pediatric Metabolic Disease
Rickets: considered osteomalacia in skeletally immature. Zone of provisional calcification of the epiphyseal growth plate is particularly affected
Clinically presents with growth retardation, extremity bowing, rachitic rosary, pigeon chest, depressed ribs, enlarged and swollen wrists, and ankles, skull deformity
Pathology: Vit D and calcium abnormality is the m/c cause. Lack of sun exposure esp. dark-skinned individual, restrictive clothing to light exposure, prolonged exclusive breastfeeding, veganism, malabsorption syndromes of the gut, renal damage and others
Imaging: frayed metaphysis aka paint brush metaphysis with flaring, widening of the growth plate, bulbous costochondral junction as a rachitic rosary, extremity bowing
Rx: treat underlying causes, correct nutritional deficit, etc.
Diagnosis of the diseases of the abdomen can be classified into:
Abnormalities of the gastrointestinal tract (esophagus, stomach, small & large bowel, and the appendix)
Abnormalities of the accessory digestive organs (Hepatobiliary & pancreatic disorders)
Abnormalities of the genitourinary & reproductive organs
Abnormalities of the abdominal wall and major vessels
This presentation aims to provide the most basic understanding of general diagnostic imaging approach and appropriate clinical management of patients with the most common diseases of the abdomen
Imaging modalities used during an investigation of the abdominal complaints:
AP abdomen (KUB) and upright CXR
Abdominal CT scanning (with oral and I.V. contrast and w/o contrast)
Upper and Lower GI Barium studies
MRI (most used as Liver MRI)
MRI enterography & enteroclysis
Endoscopic Retrograde Cholangiopancreatography (ERCP)- mostly hepatobiliary and pancreatic ductal pathology
Why Order An Abdominal X-ray?
Include a preliminary evaluation of bowel gas in an emergent setting. For example, a negative study in a low probability patient may obviate the need for a CT or other invasive procedures
Evaluation of radiopaque tubes, lines, and radiopaque foreign bodies
Post-procedural evaluation intraperitoneal/retroperitoneal free gas
Monitoring the amount of bowel gas and resolution of postoperative (adynamic) ileus
Monitoring the passage of contrast through the bowel
Colonic transit studies
Monitoring renal calculi
What to Note on AP Abdomen: Supine vs. Upright vs. Decubitus
Free Air (pneumoperitoneum)
Bowel obstruction: Dilated loops: SBO vs LBO (3-6-9 rule) SB-upper limit-3-cm, LB-upper limit-6-cm, Caecum-upper limit-9-cm. Note loss of haustra, note dilation (presence) of valvule conivente (plica semilunaris) in SBO
SBO: note different heights air-fluid levels on upright film step ladder� appearance, typical of SBO
Note paucity of rectal/colonic gas (evacuated) in SBO
Abdominal CT scanning -modality of choice during the investigation of acute and chronic abdominal complaints especially in adults. For example, abdominal malignancy can be successfully diagnosed and staged providing clinical information for care planning
Abdominal, renal and pelvic ultrasound can be performed to help the diagnosis of appendicitis (esp. in children), acute & chronic vascular pathology, hepatobiliary abnormalities, obstetric and gynecological pathology
Use of ionizing radiation (x-rays & CT) should be minimized in children and other vulnerable groups.
Diagnostic Imaging of Major Diseases of the Gastrointestinal System
1) Esophageal disorders
2) Gastric carcinoma
3) Gluten Sensitive Enteropathy
4) Inflammatory Bowel Disease
5) Pancreatic ductal adenocarcinoma
6) Colorectal carcinoma
7) Acute Appendicitis
8) Small bowel obstruction
Achalasia (primary achalasia): failure of organized esophageal peristalsis d/t impaired relaxation of the lower esophageal sphincter (LOS) with marked dilatation of the esophagus and food stasis. Obstruction of the distal esophagus (often due to tumor) has been termed “secondary achalasia” or “pseudoachalasia.� Peristalsis in the distal smooth muscle segment of the esophagus may be lost due to an abnormality of Auerbach plexus (responsible for smooth muscle relaxation). Vagus neurons can also be affected
Primary: 30 -70s, M: F equal
Chagas disease (Trypanosoma Cruzi infection) with the destruction of the Myenteric plexus neurons of the GI system (megacolon & esophagus)
However, the heart is the M/C affected organ
Clinically: Dysphagia for both solids and liquids, in comparison to dysphagia for solids only in cases of esophageal carcinoma. Chest pain and regurgitation. M/C mid esophageal squamous cell carcinoma in approximately 5% due to chronic irritation of the mucosa by stasis of food and secretions. Aspiration pneumonia may develop. Candida esophagitis
Imaging: �Bird -beak� on upper GI barium swallow, dilated esophagus, loss of peristalsis. An endoscopic exam is crucial.
Rx: difficult. Calcium channel blockers (short -term).Pneumatic dilatation, effective in 85% of patients with 3 -5% risk of bleeding/perforation. Botulinum toxin injection lasts only approx. 12 months per treatment. May scar the submucosa leading to increased risk of perforation during subsequent myotomy. Surgical myotomy (Heller myotomy)
10 -30% of patients develop gastroesophageal reflux (GERD)
Presbyesophagus: used to describe the manifestations of degenerating motor function in the aging esophagus >80-y.o. Due to interruption of the reflex arc with decreased sensitivity to distension and alteration in peristalsis.
Patients may complain of dysphagia or chest pain, but most are asymptomatic
Diffuse/distal esophageal spasm (DES) is a motility disorder of the esophagus that may appear as a corkscrew or rosary bead esophagus on barium swallow.
2% of non-cardiac chest pain
Manometry is the gold-standard diagnostic test.
Zenker diverticulum (ZD) aka pharyngeal pouch
An outpouching at the level of the hypopharynx, just proximal to the upper esophageal sphincter, known as the Killian dehiscence or Killian triangle
Patients are 60-80 y.o and present with dysphagia, regurgitation, halitosis, globus sensation
May complicate with aspiration and pulmonary abnormalities
Patients may accumulate medications
ZD- is a pseudodiverticulum or pulsion diverticulum resulting from herniation of the submucosa through the Killian dehiscence, forming a sac where food and other contents may accumulate.
Mallory-Weiss syndrome refers to mucosal and submucosal tears of the distal oesophageal venous plexus associated with violent retching/vomiting and projection of gastric contents against the lower esophagus. Alcoholics are at particular risk. Cases present with painless hematemesis. Treatment is typically supportive.
Dx: imaging plays little role, but contrast esophagram may demonstrate some mucosal tears filled by contrast (bottom right image). CT scanning may help to exclude other causes of upper GI bleeding
Boerhaave syndrome: esophageal rupture secondary to forceful vomiting
Mechanisms involve forceful expulsion of gastric contents especially with large undigested foods when esophagus forcefully contracts against closed glottis with 90% occurring along left posterolateral wall
Hiatus hernias (HH): herniation of abdominal contents through the esophageal hiatus of the diaphragm into the thoracic cavity.
Many patients with HH are asymptomatic, and it is an incidental finding. However, symptoms may include epigastric/chest pain, postprandial fullness, nausea and vomiting
Sometimes HH is considered synonymous with gastro-oesophageal reflux disease (GORD), but there is a poor correlation between the two conditions!
2-types: sliding hiatus hernia 90% & rolling (paraoesophageal) hernia 10%. The latter may strangulate leading to ischemia and complications.
Esophageal Leiomyoma is the M/C benign esophageal neoplasm. It is often large but yet non-obstructive. Gastrointestinal stromal tumors (GIST) are the least common in the esophagus. Should be differentiated from Esophageal carcinomas.
Imaging: contrast esophagram, upper GI barium swallow, CT scanning. Gastroesophagoscopy is the Dx method of choice.
Esophageal carcinoma: presented with increasing dysphagia, initially to solids and progressing to liquids with obstruction in more advanced cases
<1% of all cancers and 4-10% of all GI malignancies. There is recognized male preponderance with the squamous cell subtype due to smoking and alcohol. Barrett esophagus and adenocarcinoma
M: F 4:1. Black individuals are more susceptible than White individuals 2:1. Poor prognosis!
A barium swallow can be sensitive in identifying esophageal mass. Gastroesophagoscopy (endoscopy) confirms the diagnosis with tissue biopsy
Overall the most common malignancy is 2ndary gastric fundal carcinoma invading distal esophagus
Squamous cell is typically found in the mid esophagus, Adenocarcinoma in the distal region
Gastric carcinoma: primary malignancy of gastric epithelium. Rare before the age of 40. The median age at diagnosis in the United States is 70 years for males and 74 years for females. Japan, South Korea, Chile, and Eastern European countries have one of the highest rates of stomach cancer in the world. Stomach cancer rates are declining worldwide. Gastric cancer is the 5th causes of cancer-related death. Association with Helicobacter pylori infection 60- 80%, but only 2% population with H. Pyloris develop Stomach cancer. 8-10% have an inherited familial component.
Gastric Lymphoma is also linked to H. Pyloris infection. Gastrointestinal Stromal Cell Tumour or GIST is another neoplasm affecting the stomach
Clinically: No symptoms when it is superficial and potentially curable. Up to 50% of patients may have non-specific GI complaints. Patients may present with anorexia and weight loss (95%) as well as vague abdominal pain. Nausea, vomiting, and early satiety d/t obstruction may occur with bulky tumors or infiltrative lesions that impair stomach distension.
Prognosis: Most gastric cancers diagnosed late and may reveal local invasion with regional adenopathy, liver, and mesenteric spread. A 5-year survival rate of 20% or less. In Japan and S. Korea, early screening programmes increased survival to 60%
Imaging: Barium upper GI study, CT scanning. Endoscopic examination is the method of choice for the diagnosis. On imaging, Gastric cancer may appear as an exophytic (polypoid) mass or Fungative type, Ulcerative or Infiltrative/diffuse type (Linitis Plastica). CT scanning is important to evaluate local invasion (nodes, mesentery, liver, etc.)
Celiac disease aka non-tropical sprue aka Gluten-sensitive enteropathy: A T-cell mediated autoimmune chronic gluten-induced mucosal damage resulting in loss of villi in the proximal small bowel and gastrointestinal malabsorption (i.e., sprue). Considered in some cases of iron deficiency anemia of undetermined cause. Common in Caucasians (1 in 200) but rare in Asian and black individuals. Two peaks: a small cluster in early childhood. Typically in 3rd and 4th decades of life.
Clinically: Abdominal pain is the m/c symptom, malabsorption of nutrients/vitamins: IDA and guaiac-positive stools, diarrhea, constipation, steatorrhea, weight loss, osteoporosis/osteomalacia, dermatitis herpetiformis. Increased association with T-cell lymphoma, Increased association with esophageal squamous cell carcinoma, SBO
Dx: Upper GI endoscopy with multiple duodenal biopsies is considered a diagnostic standard for celiac disease. Histology reveals T-cell infiltration and lymphoplasmacytosis, Villi atrophy, Crypts hyperplasia, Submucosa, and Serosa are spared. Rx: elimination of gluten-containing products
Imaging: Not required for Dx but on Barium swallow fluoroscopy: mucosal atrophy and obliteration of mucosal folds (advanced cases only). SB dilation is the most typical finding. Nodularity of the duodenum (bubbly duodenum). Reversal of jejunal and ileal mucosal folds:
�The jejunum looks like ileum, the ileum looks like the jejunum, and the duodenum looks like hell.�
CD: chronic relapsing-remitting autoimmune inflammation that affects any part of the GI tract from the mouth to the anus but at onset most typically involves the terminal ileum. M/C presentation: abdominal pain/cramping and diarrhea. Path: granulomata formation that unlike UC is transmural, potentially leading to strictures. Areas affected by the inflammation are typically patchy
Complications are numerous: malabsorption of nutrients/vitamins (anemia, osteoporosis, developmental delay in children, susceptibility to GI malignancy, bowel obstruction, fistula formation, extra-abdominal manifestations: uveitis, arthritis, AS, erythema nodosum and others. 10- 20% may require abdominal surgery after 10-years of CD usually for strictures, fistiluzation, BO.
Dx: clinical, CBC, CMP, CRP, ESR, serological tests: DDx of IBD: anti-Saccharomyces cerevisiae antibodies (ASCA), perinuclear antineutrophil cytoplasmic antibody (p-ANCA) histologically or in serum. Fecal Calprotectin test helps to DDx IBS and evaluate response to treatment, disease activity/relapses.
Dx of choice: endoscopy, ileoscopy, and multiple biopsies may reveal endoscopic and histological changes. Video capsule endoscopy (VCE), Imaging may help with Dx of complications. Rx: immunomodulatory drugs, complementary medicine, diet, probiotics, operative. No cure but the aim is to induce remission, control symptoms and prevent/treat complications
Imaging Dx: KUB to DDx SBO, Barium enema (single and double contrast), small bowel follow through. Findings: skip lesions, aphthous/deep ulcerations, fistula/sinus tracts, String sign, creeping fat pushed loops of LB, cobblestone appearance d/t fissures/ulcers pushing mucosa, CT scanning with oral and IV contrast.
Imaging from a Crohn’s patient who had a small bowel resection for obstruction.
(B) MRE of the same area shows a fibrostenotic stricture
UC: characteristically involves only the colon but backwash ileitis may develop. Onset is typically at 15-40s and is more prevalent in males, but the onset after the age of 50 is also common. More common in North America and Europe (hygiene hypothesis). Etiology: A combination of environmental, genetic and gut microbiome changes are involved. Smoking and early appendectomy tend to show a negative association with UC, unlike in CD considered some of the risk factors.
Clinical Features: Rectal bleeding (common), diarrhea, rectal mucous discharge, tenesmus (occasionally), lower abdominal pain and severe dehydration from purulent rectal discharge (in severe cases, especially in the elderly), fulminant colitis and toxic megacolon can be fetal but are rare complications. Pathology: No granulomata. Ulcerations affect mucosa and submucosa. Pseudopolyps present as elevated spared mucosa.
An initial process always affects the rectum and remain a local disease (proctitis) in (25%). 30% Proximal disease extension may occur. UC may present as left-sided (55%) and pancolitis (10%). Majority of cases are mild to moderate
Imaging: not required for Dx but barium enema may reveal ulcerations, thumbprinting, in advanced cases loss of haustra and narrowing of the colon producing �lead-pipe colon.� CT scanning may help with Dx seen as mucosal thickening detected only in moderate and severe cases. CT may help with of Dx of complications. Plain film image reveals �lead-pipe colon� and sacroiliitis as Enteropathic arthritis (AS)
Colorectal carcinoma (CRC) m/c cancer of the GI tract and the 2nd most frequent malignancy in adults. Dx: endoscopy and biopsy. CT is the modalities most frequently used for staging. Surgical resection may be curative although the five-year survival rate is 40- 50% depending on staging. Risk factors: low fiber and high fat and animal protein diet, obesity (especially in men), chronic ulcerative colitis. Colonic adenomas (polyps). Familial adenomatous polyposis syndromes (Gardener syndrome) and Lynch syndrome as non-familial polyposis.
Clinically: insidious onset with altered bowel habits, fresh blood or melena, iron deficiency anemia from chronic occult blood loss especially in the right-sided tumors. Bowel obstruction, intussusception, heavy bleeding and metastatic disease especially to the Liver may be initial presentation. Path: 98% are adenocarcinomas, arise from pre-existing colonic adenomas (neoplastic polyps) with malignant transformation. The five-year survival rate is 40-50%, with stage at operation the single most important factor affecting prognosis. M/C rectosigmoid tumors (55%),
N.B. Some adenocarcinomas esp. mucinous types typically presented late and usually carry poor prognosis due to late presentation and mucin secretion and local/distant spread
Imaging: Barium enema is sensitivities for polyps >1 cm, single contrast: 77-94%, double contrast: 82-98%. Colonoscopy is a modality of choice for prevention, detection, and identification of colorectal carcinoma. Contrast-enhanced CT scanning is used for staging and prognosis evaluation of mets.
Screening: colonoscopy: men 50 y.o.-10-years if normal, 5-years if polypectomy, FOB, 1st degree relative with CA begin surveillance at 40 y.o
Pancreatic Cancer: ductal epithelial adenocarcinoma (90%), very poor prognosis with high mortality. 3rd M/C abdominal cancer. Colon is #1, stomach #2. Pancreatic cancer accounts for 22% of all deaths due to gastrointestinal malignancy, and 5% of all cancer deaths. 80% of cases in 60+. Cigarette smoking is the strongest environmental risk factor, a diet rich in animal fats and protein. Obesity. Family history. M/C detected in the head and uncinate process.
Dx: CT scanning is crucial. Invasion of Superior Mesenteric Artery (SMA) indicates unresectable disease. 90% of pancreatic adenocarcinomas are unresectable at Dx. Most patients die within 1-year of Dx. Clinically: painless jaundice, abd. Pain, Courvoisier�s gallbladder: painless jaundice and enlarged gallbladder, Trousseau�s syndrome: migratory thrombophlebitis, new onset diabetes mellitus, regional and distant metastasis.
CT Dx: pancreatic mass with strong desmoplastic reaction, poor enhancement, and slightly lower attenuation compared to the adjacent normal gland, SMA invasion.
Appendicitis: very common condition in general radiology practice and is a major cause of abdominal surgery in young patients
CT is the most sensitive modality to detect appendicitis
Ultrasound should be employed in younger patients and children
KUB Radiographs should play no role in the diagnosis of appendicitis
On imaging, appendicitis reveals inflamed appendix with wall thickening, enlargement, and periappendiceal fat stranding. Similar findings of wall thickening and enlargement are noted on US. Typical �target sign� is noted on short axis US probe position.
If the appendix is retro-caecal than US may fail to provide accurate Dx and CT scanning may be required
Rx: operative to avoid complications
Small bowel obstruction (SBO)-80% of all mechanical intestinal obstruction; the remaining 20% result from large bowel obstruction. It has a mortality rate of 5.5%
M/C cause: any Hx of previous abdominal surgery and adhesions
Classical presentation is constipation, increasing abdominal distension with nausea and vomiting
Radiographs are only 50% sensitive for SBO
CT will demonstrate the cause of SBO in 80% of cases
There are variable criteria for maximal small bowel obstruction, but 3.5 cm is a conservative estimate of dilated bowel
On Abd x-ray: supine vs. upright. Dilated bowel, stretched valvulae conivente (mucosal folds), alternative air-fluid levels �step ladder.� Absent gas in the rectum/colon
Rx: operative as �acute abdomen.�
Volvulus-m/c in the Sigmoid colon esp. in elderly. The main reason: chronic constipation with redundant sigmoid twisting on sigmoid mesocolon. Leads to Large bowel obstruction (LBO). Other common causes: a colon tumor. Sigmoid vs. Caecum volvulus
Clinically: signs of LBO with constipation, abdominal bloating, pain, nausea, and vomiting. Onset may be acute or chronic
Radiographically: loss of haustra in the LB, LB distension (>6-cm), �coffee bean sign� next slide, the lower end of volvulus points to the pelvis
N.B: Rule of thumb for dilated bowel should be 3-6-9 where 3-cm SB, 6-cm LB & 9-cm Coecum
Note generations of the tracheal-bronchial tree, lobes, segments, and fissures. Note secondary pulmonary lobule (1.5-2-cm)-the basic functional unit of lungs observed on HRCT. Note important structural organization of the alveolar spaces with communications in between (pores of Kohn & canals of Lambert) that permit air drift and by the same mechanism allow exudative or transudative fluid to spread through the lung and stopped at the fissure. Note the anatomy of the pleura: parietal that is a part of the endothoracic fascia and the visceral that forms a lung edge � pleural space in between.
Mediastinum: surrounded by the pleura and the lung. Accommodates major structures contains numerous lymph nodes (see diagramme showing mediastinal nodes and their involvement in Lymphoma
General Approach to Investigating Chest Complaints
Decubitus views right and left: help to evaluate subtle pleural effusion, pneumothorax and other pathology
Normal CXR PA & Lateral views. Ensure good exposure: T-spine discs and vessels through the heart are visualized on PA view. Count 9-10 right posterior ribs to confirm adequate inspiratory effort. Begin a thorough survey using the following approach: Are There Many Lung Lesions A-abdomen/diaphragm, T-thorax wall, M-mediastinum, L-lungs individually, Lungs-both. Develop a good search pattern
1) Airspace disease aka alveolar lung disease? Filling of the lung’s alveoli, acini and subsequently the entire lobe with fluid or substance of any composition (blood, pus, water, proteinaceous material or even cells) Radiographically: lobar or segmental distribution, airspace nodules may be noted, tendency to coalesce, air bronchograms and silhouette sign present. Batwing (butterfly) distribution noted as in (CHF). Rapidly changing over time, i.e., increase or decrease (days)
2) Interstitial disease: infiltration of pulmonary interstitium (alveoli septum, lung parenchyma, vessel walls, etc.) by for example by viruses, small bacteria, protozoans. Also infiltration by cells such as inflammatory/malignant cells (e.g., lymphocytes) Presented as an accentuation of lung interstitium with a reticular, nodular, mixed reticulonodular pattern. Different etiologies: inflammatory autoimmune diseases, fibrosing lung disease, occupational lung disease, viral/mycoplasma infection, TB, sarcoidosis lymphoma/leukemia and many other.
Recognizing different patterns of pulmonary disease can help with DDx. Mass vs. Consolidation (left). Note different patterns of pulmonary disease: airspace disease as lobar consolidation indicative of pneumonia, diffuse consolidation indicative of pulmonary edema. Atelectasis (collapse and volume loss). Interstitial patterns of pulmonary disease: reticular, nodular or mixed. SPN vs. Multiple focal consolidations (nodules) likely representing mets infiltrates vs. septic infiltrates
A = intraparenchymal
B = pleural
C = extrapleura
Recognize important location of chest lesions
Important signs: Silhouette sign: help with localization and DDx. Example: Bottom left image: radiopacity in the right lung, where is it located? Right MM because the right heart border that is adjacent to right middle lobe is not seen (silhouetted) Air bronchograms: air containing bronchi/bronchioles surrounded by fluid
Pneumothorax (PTX): air (gas) in the pleural space. Many causes. Complications:
Tension PTX: continuous increase of air in the pleural space that rapidly compresses mediastinum and lung rapidly reducing venous return to the heart. It can be fatal if not treated rapidly
Spontaneous PTX: primary (young adults (30 -40) especially tall, thin men. Additional causes: Marfan�s syndrome, EDS, Homocystinuria, a – 1 -antitrypsin deficiency. Secondary: older pts with parenchymal disease: neoplasms, abscess, emphysema, lung fibrosis and honeycombing, catamenial PTX d/t endometriosis and others.
CXR: note visceral pleural line aka lung edge. An Absence of pulmonary tissue/vessels beyond the visceral pleural line. Subtle pneumothorax can be missed. On erect position, air rises and PTX should be sought at the top.
Rib fractures: v.common. Traumatic or pathological (e.g., mets, MM) Rib series x – rays are not very useful because CXR and/or CT scanning are more important to evaluate posttraumatic PTX (bottom left) lung laceration and another major path
Pneumonia: bacterial vs. viral or fungal or in the immunocompromised host (e.g., Cryptococcus in HIV/AIDS) Pulmonary TB
Pneumonia: community-acquired vs. hospital-acquired. Typical bacterial pneumonia or Lobar (non-segmental) pneumonia with purulent material filling the alveoli and spreading to the entire lobe. M/C organismStreptococcus Pneumonia or the Pneumococcus
Others: (Staph, Pseudomonas, Klebsiella esp. in alcoholics potentially leading to necroSIS/lung gangrene) Mycoplasma (20-30s) aka walking pneumonia, etc.
Clinically: a productive cough, fever, pleuritic chest pain sometimes hemoptysis.
CXR: confluent airspace opacity confined to the entire lobe. Air bronchograms. Silhouette sign help with location.
Viral: Influenza, VZV, HSV, EBV, RSV, etc. presents as interstitial lung disease that can be bilateral. May lead to respiratory compromise
Atypical pneumonia and Fungal Pneumonia: Mycoplasma, Legionnaire’s disease, and some fungal/Cryptococcus pneumonia may present with interstitial lung disease.
Pulmonary abscess: an infectious collection of purulent material in the lungs that often necrotizes. May lead to significant pulmonary and system complications/life-threatening.
On CXR or CT: round collection with thick borders and central necrosis containing air-fluid level. DDx from empyema that distorts the lung and pleural-based
Rx: antibiotics, antifungal, antiviral agents.
Pneumonia needs to be followed up with repeat CXR to ensure complete resolution
Lack of radiographic improvement of pneumonia may represent declined immunity, antibiotic resistance, underlying lung carcinoma or other complicating factors
Common infection worldwide (3rd world countries). 1 in 3 persons worldwide is affected by TB. TB is caused by Mycobacterium TB or Mycobacterium Bovis. Intracellular bacillus. Macrophage plays a key role.
Primary Pulmonary TB & Post-primary TB. Requires repeated exposure through inhalation. In most immunocompetent hosts, the active infection does not develop
TB presents as 1) cleared by the host, 2) suppressed into Latent Tuberculosis Infection (LTBI) 3) cause active disease TB. Patients with LTBI are not spreading TB.
Imaging: CXR, HRCT. Primary TB: pulmonary airspace consolidation (60%) lower lobes, lymphadenopathy (95%- hilar & paratracheal), pleural effusion (10%). The Spread of primary TB most likely in immunocompromised and children.
Milliary TB: pulmonary and system complication dissemination that can be fatal
Post-primary (secondary) or reactivation infection: Mostly in the Apices and posterior segments of the upper lobes )high PO2), 40%-cavitating lesions, patchy or confluent airspace disease, fibrocalcific. Latent features: nodal calcifications.
Dx: Acid-fast bacilli (AFB) smear and culture (sputum). HIV serology in all patients with TB and unknown HIV status
Rx: 4-drug regimen: isoniazid, rifampin, pyrazinamide, and either ethambutol or streptomycin.
Pulmonary Neoplasms (primary lung cancer vs. pulmonary metastasis)
Lung cancer: m/c cancer in men and 6th most frequent cancer in women. Strong association with carcinogens inhalation. Clinically: late discovery, depending on the location of the tumor. Pathology (types): Small cell (SCC) vs. Non-small cell carcinoma
Small cell: (20%) develops from neuroendocrine aka Kultchitsky cell, thus may secrete biologically active substances presenting with paraneoplastic syndrome. Typically located centrally (95%) at or near the mainstem/lobar bronchus. Most show poor prognosis and unresectable.
Non-small cell: Lung adenocarcinoma (40%) (M/C lung cancer), M/C in women and non-smokers. Others: Squamous cell (may present with cavitating lesion), Large cell and some others
Plain film (CXR): new or enlarged focal lesion, widened mediastinum suggestive of lymph node involvement, pleural effusion, atelectasis, and consolidation. SPN-may represents potential lung cancer especially if it contains irregular borders, feeding vessels, thick wall, in the upper lungs. Multiple lung nodules are likely to represent metastasis.
Best Modality: HRCT with contrast.
Other chest neoplasms: Lymphoma is v. common in the chest especially in mediastinal and internal mammary notes.
Overall M/C pulmonary neoplasms are a metastasis. Some tumors show a higher predilection for lung mets, e.g., Melanoma, but any cancer can metastasize to the lungs. Some mets referred as �Cannonball� metastasis
Rx: radiation, chemotherapy, resection
Pulmonary edema: a general term defines abnormal fluid accumulation outside vascular structures. Broadly divided into Cardiogenic (e.g., CHF, mitral regurgitation) and Non-cardiogenic with a multitude of causes (e.g., fluid overload, post-transfusion, neurological causes, ARDS, near drowning/asphyxiation, heroin overdose, and others)
Causes: increased in Hydrostatic pressure vs. decreased in oncotic pressure.
Imaging: CXR and CT: 2-types Interstitial and Alveolar flooding. Imaging presentation depends on stages
In CHF: Stage 1: redistribution of vascular flow (10- 18-mm Hg) noted as �cephalization� of the pulmonary vasculature. Stage 2: Interstitial edema (18-25-mm Hg) Interstitial edema: peribronchial cuffing, Kerley lines (lymphatics filled with fluid) A, B, C lines. Stage 3: Alveolar edema: airspace disease: patchy consolidations developing into diffuse airspace disease: Batwing edema, air bronchograms
Rx: 3 main goals: Initial O2 to keep O2 at 90% saturation
Next: (1) reduction of pulmonary venous return (preload reduction), (2) reduction of systemic vascular resistance (afterload reduction), and (3) inotropic support. Treat underlying causes (e.g., CHF)
Lung atelectasis: incomplete expansion of pulmonary parenchyma. The term “collapsed lung” is typically reserved for when the entire lung is collapsed
1) Resorptive (obstructive) atelectasis occurs as a result of complete obstruction of an airway (e.g. tumor, inhaled objects, etc.)
2) Passive (relaxation) atelectasis occurs when contact between the parietal and visceral pleura is disrupted (pleural effusion & pneumothorax)
3) Compressive atelectasis occurs as a result of any thoracic space-occupying lesion compressing the lung and forcing air out of the alveoli
4) Cicatricial atelectasis: occur as a result of scarring or fibrosis that reduces lung expansion as in granulomatous disease, necrotizing pneumonia, and radiation fibrosis
5) Adhesive lung atelectasis occurs from surfactant deficiency and alveolar collapse
6) Plate-like or discoid often developed after following general anesthesia
7) Imaging features: lung collapse, migration of lung fissures, deviation of the mediastinum, rising of the diaphragm, hyperinflation of adjacent unaffected lung
Mediastinum: pathology can be divided into those that result in a focal mass or those that result in diffuse disease involving the mediastinum. Additionally, air may track into the mediastinum in pneumomediastinum. Knowledge of mediastinal anatomy helps the Dx.
Pulmonary emphysema: loss of normal elastic tissue/elastic recoil of the lung with the destruction of capillaries and alveolar septum/interstitium.
Destruction of lung parenchyma due to chronic inflammation. Protease-mediated destruction of elastin. Air trapping/airspace enlargement, hyperinflation, pulmonary hypertension, and other changes. Clinical: progressive dyspnea, irreversible. By the time the forced expiratory volume in 1 second (FEV1 ) has fallen to 50% the patient is breathless upon minimal exertion and adapts to lifestyles.
COPD is the third leading cause of global death. Affects 1.4% of adults in the US. M:F = 1 : 0.9. Pts 45 years and older
Causes: Smoking and a-1-Antitrypsin deficiency (divided into centrilobular (smoking) and panacinar.
Imaging; signs of hyperinflation, air trapping, bullae, pulmonary hypertension.
SKULL FX: COMMON IN THE SETTINGS OF HEAD INJURIES. SKULL FX OFTEN POINT TO OTHER COMPLICATING FACTORS: INTRA-CRANIALHEMORRHAGING, CLOSED TRAUMATIC BRAIN INJURY AND OTHER SERIOUS COMPLICATIONS
SKULL X-RAYS ARE VIRTUALLY OBSOLETE IN EVALUATING HEAD INJURY. CT SCANNING W/O CONTRAST IS THE MOST IMPORTANT INITIAL STEP IN EVALUATION OF ACUTE HEAD TRAUMA. MRI HASA POOR ABILITY TO REVEAL SKULL FRACTURES, AND NOT TYPICALLY USED FOR AN INITIAL DX OF ACUTE HEAD TRAUMA.
SKULL FX ARE IDENTIFIED AS FXS OF SKULL VAULT, SKULL BASE AND FACIAL SKELETON EACH ASSOCIATED WITH SPECIFIC FEATURES AND HELP TO PREDICT COMPLICATIONS.
LINEAR SKULL FX: SKULL VAULT. M/C FX. CT SCANNING IS THE KEY TO EVALUATE ARTERIALEXTRADURAL HEMORRHAGING
X-RAY DDX: SUTURES VS. LINEAR SKULL FX. FX IS THINNER, �BLACKER� I.E. MORE LUCENT, CROSSESSUTURES,�AND VASCULAR GROOVES, LACKSSERRATIONS
RX: IF NO INTRACRANIAL BLEEDS THAT NO TREATMENT. NEUROSURGICAL CARE IF BLEEDSDETECTED BY CT SCANNING
DEPRESSED SKULL FX: 75% IN THE VAULT. CAN BE DEADLY. CONSIDERED AN OPEN FX. MOST CASES NEED NEUROSURGICALEXPLORATION ESPECIALLY IFFRAGMENTS DEPRESSED >1-CM.COMPLICATIONS: VASCULAR INJURY/HEMATOMAS, PNEUMOCEPHALUS, MENINGITIS, TBI, CSF LEAK, BRAIN HERNIATION ETC.
IMAGING: CT SCANNING W/O CONTRAST
BASILAR SKULL FX: CAN BE DEADLY. OFTEN ALONG OTHER MAJOR HEAD TRAUMA OF THE VAULT AND FACIALSKELETON, OFTEN WITH TBI AND MAJORINTRACRANIAL HEMORRHAGING. OFTEN OCCUR AS �HEADBAND� EFFECT OF IMPACT AND MECHANICAL TENSION THROUGH THE OCCIPUT AND TEMPORAL BONES THROUGH SPHENOID AND OTHER BASE OF SKULL BONES. CLINICALLY: RACCOON EYES, BATTEL SIGN, CSFRHINO/OTORRHEA.
NASAL BONES FX: 45% OF ALLFACEFXM/C IMPACT IS LATERAL(FIST BLOW ETC.) IF UNDISPLACEDNO TREATMENT, IF DISPLACED MAY COMPLICATE AIR FLOW AND RESPIRATORY PASSAGE, MAY BE ASSOCIATED WITH OTHER FACIAL/SKULL INJURY. X-RAYS 80%SENSITIVE, FOLLOWED BY CT INCOMPLEX INJURIES.
ORBITAL BLOW OUT FX: COMMONORBITAL INJURY D/T IMPACT ON THE GLOBE AND/OR ORBITAL BONE. FX OF ORBITAL FLOOR INTOMAXILLARY SINUS VS. MEDIAL WALL INTO ETHMOID SINUS. COMPLICATIONS: ENTRAPPEDINFERIOR RECTUS M, PROLAPSEORBITAL FAT,�AND SOFT TISSUES, HEMORRHAGING AND OPTIC NERVE DAMAGE. RX: CONCERNS OF GLOBE INJURY ARE IMPORTANT, GENERALLY TREATEDCONSERVATIVELY IF NO COMPLICATIONS PRESENT
TRIPOD FX: 2ND M/C FACIAL FX#AFTER NASAL (40% OF MIDFACEFX) 3-POINT FX-ZYGOMATICARCH, ORBITAL PROCESS OF ZYGOMATIC BONE & SIDE OF MAXILLARY SINUS WALL, MAXILLARY PROCESS OF ZYGOMATIC BONE.COMPLICATED BY NERVE INJURY, TEMPORALIS M DAMAGE ETC. CT SCANNING IS MORE INFORMATIVE THAT X-RAYS (WATER�S VIEW).
LEFORT FX: SERIOUS FX ALWAYS INVOLVES PTERYGOID PLATES, POTENTIALLY SEPARATINGMIDFACE AND ALVEOLAR PROCESS WITH TEETH FROM THE SKULL. CONCERNS: AIRWAYS, HEMOSTASIS, NERVE INJURIES. CT SCANNING IS REQUIRED. POTENTIAL RISK OF BASILAR SKULL FX
PING-PONG FX:�EXCLUSIVELY IN INFANTS. AN INCOMPLETE FX D/T FOCALDEPRESSION: FORCEPS DELIVERY, DIFFICULT LABOUR ETC. FOCALTRABECULAR MICROFRACTURIINGLEAVING DEPRESSION RESEMBLING APING-PONG. DX IS MAINLY CLINICALSEEN AS FOCAL DEFECT �DEPRESSION� IN THE SKULL. TYPICALLYNEUROLOGICALLY INTACT. CT MAY HELP IF BRAIN INJURY IS SUSPECTED. RX: OBSERVATIONAL VS. SURGICAL IN COMPLICATED INJURIES. SPONTANEOUSREMODELING HAS BEEN REPORTED
LEPTOMENINGEAL CYST (GROWING SKULL FX)- ARE AN ENLARGING SKULL FRACTURE THAT DEVELOPS ADJACENT TO POSTTRAUMATIC ENCEPHALOMALACIA
IT IS NOT A CYST, BUT AN EXTENSION OF THEENCEPHALOMALACIA THAT SEEN A FEW MONTHS POST-TRAUMA WITH PREVIOUS SKULL FX FOLLOWEDBY HERNIATION OF THE MENINGES AND ADJACENTBRAIN WITH PULSATIONS OF THE CSF. CT IS BEST ATDX THIS PATHOLOGY. INDICATES: GROWING FX AND ADJACENT ENCEPHALOMALACIA AS FOCALHYPOATTENUATING LESION.
DDX: INFILTRATING CELLS/METS/OTHER NEOPLASMSINTO SUTURES, EG, INFECTION ETC.
MANDIBULAR FXS: COMMON. POTENTIALLYCONSIDERED AN OPEN FX D/T INTRA-ORALEXTENSION. 40% FOCAL BREAK DESPITEMANDIBLE BEING A RING. DIRECT IMPACT(ASSAULT) M/C MECHANISM
PATHOLOGICAL FX D/T BONE NEOPLASMS, INFECTION ETC. IATROGENIC DURING ORAL SURGERY (TOOTH EXTRACTION)
IMAGING: MANDIBLE X-RAYS, PANOREX, CT SCANNING ESP. IN CASES OF ASSOCIATEDFACE/HEAD TRAUMA
COMPLICATIONS: AIRWAY OBSTRUCTION, HEMOSTASIS IS A MAJOR CONSIDERATION, DAMAGE TO MANDIBULAR N, OSTEOMYELITIS/CELLULITIS AND POTENTIAL SPREAD THROUGH FLOOR OF THE MOUTH (LUDWIGANGINA) AND NECK FASCIAL SOFT TISSUES INTOMEDIASTINUM. CANNOT BE NEGLECTED D/T HIGH MORTALITY RATES.
RX: CONSERVATIVE VS. OPERATIVE
Acute Intracranial Hemorrhage
EPI AKA EXTRADURAL: (EDH) TRAUMATIC RAPTURE OF MENINGEAL ARTERIES (MMA CLASSIC) WITH RAPIDLY FORMING HEMATOMA BETWEEN THE INNER SKULL AND OUTER DURA. CT SCANNING IS THE KEY TO DX: PRESENTS AS �LENTIFORM� I.E. BICONVEX COLLECTION OF ACUTE (HYPERDENSE) BLOOD THAT DOES NOT CROSSSUTURES AND HELPS WITH DDX OF A SUBDURAL HEMATOMA. CLINICALLY: HA, LUCID EPISODE INITIALLY AND DETERIORATING IN A FEW HOURS.COMPLICATIONS: BRAIN HERNIATION, CN PALSY. O/A GOOD PROGNOSIS IF QUICKLY EVACUATED.
SUBDURAL HEMATOMA (SDH): RAPTURE OF BRIDGINGVEINS BETWEEN INNER DURA AND THE ARACHNOID.SLOW BUT PROGRESSIVE BLEED. MAY PARTICULARLYAFFECT THE VERY YOUNG AND ELDERLY AND IN ALL AGES (MVA, FALLS ETC.) MAY DEVELOP IN �SHAKEN BABY SYNDROME�. DX MAY BE DELAYED AND WORSEN THE PROGNOSIS WITH HIGH FATALITIES. IN ELDERLY HEAD TRAUMA MAY BE MINOR OR NOT RECALLED. EARLYIMAGING WITH CT IS CRUCIAL. PRESENTS AS CRESCENTSHAPEDCOLLECTION THAT CAN CROSS SUTURES BUT STOPPED AT DURAL REFLECTIONS. DIFFERENTATTENUATION ON CT D/T DIFFERENT STAGES OF BLOODDECOMPOSITION: ACUTE, SUBACUTE,�AND CHRONIC.MAY FORM A CHRONIC COLLECTION-CYSTICHYGROMA. CLINICALLY: VARIABLE PRESENTATION, 45-60% PRESENT WITH SEVERELY DEPRESSED CNS STATUS, PUPILLARY INEQUALITY. OFTEN WITH INITIAL BRAIN CONTUSION, THEN A LUCID EPISODE BEFORE SEVERELYDETERIORATING. IN 30% CASES OF FATAL BRAIN INJURY PATIENTS HAD SDH. RX: URGENT NEUROSURGICAL.
SUBARACHNOID HEMORRHAGE (SAH): BLOOD IN THE SUB-ARACHNOID SPACE AS THE RESULT OF TRAUMATIC OR NON-TRAUMATIC ETIOLOGY: BERRY ANEURYSMS AROUND CIRCLE OF WILLIS.SAH 3% OF STROKES, 5% OF FETAL STROKES.CLINICALLY: PRESENTS AS A �THUNDERCLAP HEADACHE� DESCRIBED AS A �WORST HA INLIFE�. PT COLLAPSES MAY OR MAY NOT REGAIN CONSCIOUSNESS. PATHOGY: DIFFUSE BLOOD INSA SPACE 1)SUPRASELLAR CISTERN WITH DIFFUSE PERIPHERAL EXTENSION, 2)�PERIMESENCEPHALIC, 3) BASAL CISTERNS. BLOOD LEAKED INTO SA SPACE UNDERARTERIAL PRESSURE INDUCES GLOBAL INCREASE IN INTRACRANIAL PRESSURE, ACUTE GLOBAL ISCHEMIA WORSENED BY VASOSPASM AND OTHER CHANGES.
DX: IMAGING: URGENT CT SCANNING W/O CONTRAST, CT ANGIOGRAPHY MAY HELP TO RULE OUT 99% OF SAH. LUMBAR PUNCTUREMAY HELP IN DELAYED PRESENTATION. AFTER INITIAL DX: MR ANGIOGRAPHY HELPS TO FIND THE CAUSE AND OTHER IMPORTANT FEATURES
IMAGING FEATURES: ACUTE BLOOD IS HYPERDENSE ON CT. FOUND IN DIFFERENTCYSTERNS: PERIMESENCEPHALIC, SUPRASELLA, BASAL, VENTRICLES,
RX: INTRAVENOUS ANTIHYPERTENSIVE MEDS, OSMOTIC AGENTS (MANNITOL) TO DECREASEICP. NEUROSURGICAL CLIPPING AND OTHER APPROACHES.
CNS Neoplasms: Benign vs. Malignant
BRAIN TUMORS REPRESENT 2% OF ALL CANCERS. ONE THIRD ARE MALIGNANT, OF WHICH METASTATIC BRAIN LESIONS ARE THE MOST COMMON
CLINICALLY PRESENT WITH LOCAL CNS ABNORMALITIES, INCREASED ICP, INTRACEREBRAL BLEEDING ETC. FAMILIALSYNDROMES: VON-HIPPEL-LANDAU, TUBEROUS SCLEROSIS, TURCOT SYNDROME, NF1 & NF2 INCREASE THE RISK. IN CHILDREN: M/C ASTROCYTOMAS, EPENDYMOMAS, PNETNEOPLASMS (E.G. MEDULLOBLASTOMA) ETC. DX: BASED ON WHO CLASSIFICATION.
IMAGING IS CRUCIAL: INITIAL SYMPTOMS MAY PRESENT AS SEIZURE, ICP SIGNS HA. EVALUATED BY CT AND MRI WITH IV GADOLINIUM.
IMAGING DETERMINES: INTRA-AXIAL VS. EXTRA-AXIALNEOPLASMS. METS FROM PRIMARY BRAIN NEOPLASMS MAYO CCUR VIA CSF AND LOCAL VESSELS INVASION
NOTE AXIAL CT SLICE OF MENINGIOMA WITH AVIDCONTRAST ENHANCEMENT.
AXIAL MRI ON FLAIR PULSE SEQUENCE REVEALED EXTENSIVE NEOPLASM AND MARKED CYTOTOXIC EDEMA OF THE BRAIN PARENCHYMA CHARACTERISTIC OF GRADE IV GLIOMA (GBM) WITH VERY POOR PROGNOSIS. ABOVE FAR RIGHT IMAGE: AXIAL MRI FLAIR: BRAIN METASTASIS FROM BREAST CANCER. MELANOMA IS COMMONLY METASTASIZESTO THE BRAIN (SEE PATH SPECIMEN) MRI CAN BE DIAGNOSTIC D/T HIGH SIGNAL ON T1 AND CONTRAST ENHANCEMENT.
RX: NEUROSURGICAL, RADIATION, CHEMOTHERAPY,�IMMUNOTHERAPY TECHNIQUES ARE EMERGING
Most healthcare providers use x-rays as a diagnostic tool to treat a variety of patient complaints, including chiropractors. They can help doctors identify the source of a problem or if there is something more going on. X-rays can also help chiropractors determine the best course of action for treatment. To understand more, let’s take a closer look at what they are and how they’re used in most chiropractic offices.
What are x-rays?
An x-ray is a very vigorous form of electromagnetic radiation that is similar to radio waves, ultraviolet radiation, microwaves, or visible light that is used to view the internal composition of a person or thing. A beam is focused on a specific part of a person�s body, such as the back, it produces a digital image of the skeletal structure.
The beam passes easily through skin and other soft tissues�but is unable to pass through bone and teeth. Soft tissue that is denser, such as organs, ligaments, and muscles, will be visible�but will be captured in shades of gray. Areas like the bowel or lungs appear on the film as black.
The use of chiropractic x-rays
Chiropractic x-rays provide vital information that can affect how the chiropractor chooses to treat a patient. In some cases, chiropractic care or spinal manipulation may not be an appropriate course of action at that time, and the patient may be started on a different, gentler therapy.
Other times, it can show the chiropractor how to best proceed in treating the patient. In short, patients can receive better, more well-rounded care which can better facilitate their healing and pain management.
Identify a condition or symptom, such as a spinal tumor or lesion�that would provide a medical reason that a specific course of care should not be done.
Obtain important biomechanical information that can aid in guiding treatment.
To stay apprised and maintain a record of a patient�s degenerative process.
Aid in identifying anomalies in the spine and joints that can affect treatment.
Allows patients to understand their condition and treatment plan better, allowing them to take ownership of the process and be more involved in their therapy and healing.
What does a chiropractor look for on an x-ray film?
When a chiropractor takes an x-ray of a patient, they are looking for things in several particular areas. The first thing they check is to make sure that there are no dislocations, fractures, cancer, infections, tumors, or other potentially dangerous conditions.
They then look for disk height and other signs of disk degeneration, bone density, bone spurs, joint spaces, and alignment. This allows them to identify conditions like scoliosis and other conditions that may require specific forms of treatment.
Many chiropractors prefer that the patient is in a weight-bearing position when taking spinal x-rays. This differs from the majority of medical facilities which have the patient lie down.
The advantage of weight-bearing x-rays as a diagnostic tool�is that it allows for measuring, i.e., leg length deficiency, scoliosis, and the narrowing of joint space. It can also show that certain bones, such as the tibia and fibula, are separating which can be an indication of a torn tendon or problem with the joint. A non-weight bearing x-ray cannot provide the same perspective,�and vital clues to a patient�s condition may be missed.
IFM's Find A Practitioner tool is the largest referral network in Functional Medicine, created to help patients locate Functional Medicine practitioners anywhere in the world. IFM Certified Practitioners are listed first in the search results, given their extensive education in Functional Medicine