Ultrasound / Interventional Radiology
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CURRENT PATHOLOGY IMAGING GUIDELINES
CONTENTS
A. Neck and thoraxF. Spine
Imaging resources
- 1. Trauma
- 2. Infection
- 3. Tumor
- 4. Degenerative diseases
G. Extremities
Standing AP and lateral radiographs (very useful before any further imaging)
- static disorders: pelvis lateral tilt, scoliosis, exagerated kyphosis, hyperlordosis, rigidity, spondylolisthesis, subluxation
- vertebra and posterior elements: transitional abnormalities, malformations, fracture, avulsion, luxation, lytic or sclerotic lesions, osteopenia, collapse, posterior joint osteoarthritis, spinal stenosis
- vertebral discs: collapse, intradiscal gas, erosion or sclerosis of vertebral endplates, osteophytes
- soft tissues: paravertebral swelling, calcifications (post. longitudinal lig., yellow ligaments, annulus fibrosus, nucleus pulposus), paralytic ileus, aorta, etc.
- Other bone elements: sacrum, coccyx (better demonstrated by a localised lateral view), sacroiliac joints, pelvis, hips
Oblique views
- in cervical spine: visualisation of foramina, posterior facets
- in lumbar spine: allows analysis of vertebral isthms (spondylolysis)
Flexion-extension or lateral inclination (after standard views study)
- may show posttraumatic vertebral or posterior joints subluxation (cervical spine)
- anteroposterior stability disorders
- to distinguish a postural from a fixed scoliosis
- contraindications: fracture or luxation not excluded, dens subluxation (rheumatoid arthritis)
Transbuccal projection (A-P)
- C1-C2 joint
- dens and ligament lesions
Barsony projection
- sacroiliac joints (now better analysed by CT-scan)
- may show a spondylolysis at L5 level
- sacrum study
Myelography
- subarachnoidal space opacification through lumbar or suboccipital puncture
- almost always replaced by MRI sequences
Radiculography
- lumbosacral sac opacification through lumbar puncture
- sometimes useful before operation in addition to MRI in an ambiguous case (intraforaminal hernia, suspicion of recurrent disc hernia)
- often associated to CT-scan (myeloCT)
MRI
- after standard radiographs, best option for all spine segments, especially cervical spine (CT-scan images unsatisfactory due to shoulder artifacts) and long segments (dorsal column)
- suspicion of disc hernia recurrence after operation
- bone diseases (infection, inflammation, tumoral infiltration)
- best depiction of discal disorders, spinal canal lesions (tumors, collections, etc.) and paravertebral spaces
- myelographic sequences
CT-scan
- spine trauma
- good depiction of bony stenoses (older patients, severe osteoarthritis, suspicion of spinal canal stenosis)
- may be added to a myeloradiculography
- guidance in interventional radiology (diagnostic puncture, therapeutic infiltration, vertebroplasty)
- limited field of view, no direct sagittal sections, suboptimal tissue resolution (disc substance), less accurate for recurrent disc hernia
- most often replaced by MRI for: disc hernias, spondylodiscitis, neoplasia, operated patients
PROBLEM MANAGEMENT
1. Trauma
- CT-scan with multiplanar reconstructions: trauma work-up
- Plain films: osteopenia, fracture, bone avulsion, subluxation, luxation, angulation
- transbuccal: suspicion of dens fracture
- flexion views (cervical spine): posterior joints instability
- MRI: cord lesion, posterior wall, pathologic fracture, disc hernia
2. Infection
- Plain films: disc space narrowing, vertebral endplate erosion, scoliosis, paravertebral swelling
- MRI: first choice imaging tool for spondylodiscitis, extent of infection, paravetebral spread
- CT-scan: extent of bony destruction, abscess, guided puncture, drainage
- scintigraphy: search for occult infection site
3. Tumors
- Plain films: osteolysis, pathologic fractures, vertebral alignment, distant lesions, vertebral angioma
- MRI:tumor extension, spinal canal invasion, paravertebral invasion, skip lesions, treatment monitoring
- CT-scan: bone destruction, posterior elements, specific lesions (osteoblastoma, vertebral angioma, bone sclerosing metastasis), guided diagnostic punctures. Thoraco-abdominal metastatic work-up.
- scintigraphy: depiction of bone metastases (breast, prostate, lung, kidney, thyroid tumors, etc.)
4. Degenerative and inflammatory diseases
- Plain films: static disorders, malformations, disc space narrowing, osteophytosis, posterior elements osteoarthritits, osteopenia, vertebral collapse, erosion, calcification (DISH), ostéochondrosis (Scheuermann's disease)
- MRI: radiculalgia with neurological deficit (disc hernia, intracanalar synovial cyst, posterior joints osteoarthritits, foraminal stenosis), prolonged pain not responding to treatment, neurogenic claudication (spinal canal stenosis)
- CT-scan: may replace MRI for some lumbar spine indications (older or restless patients, complement after radiculography)
5. Malformation, scoliosis
- Plain films (for a scoliosis, 2 segments at least, i.e. cervical+thoracic or thoracic+lumbar, or total spine film); scoliosis angle measurements
- Obliques ± Barsony: spondylolisthesis
- Functional views: stability and reversibility of scoliosis, hyperkyphosis or hyperlordosis
- MRI: Chiari malformation, hydromyelia, tethered cord, sacrococcygian lipoma, meningocele
- CT-scan: complex vertebral malformations, diastematomyelia, post-operative status (metallic elements precluding use of MRI)
- ultrasound (infants and small children): posterior arch closing defects and tethered cord.
Pierre Bénédict, MD, FMH radiologist, Lausanne, 1997-2008
References:
- Eisenberg R.L., Margulis A.R.: "Radiology Pocket Reference: what to order when", Lippincott, 2nd ed., 1999
- ACR (American College of Radiology) guidelines
- Radiation protection 118: Referral guidelines for imaging (Office for official publications of the European Communities)
- Paul Rodriguez "MRI Indications for the Referring Physician", Aurora, 1997