Abstract
Anatomy: 33 normal vertebra with 24 presacral segments: 7 cervical, 12 thoracic rib-bearing and 5 lumbar non-rib-bearing. Approximately 5 % of population with variant transitional anatomy with lumbarization of S1 or sacralization of L5 due to partial fusion of transverse process with sacrum, which may predispose to Bertolotti’s syndrome, which can be a source of back pain caused by the transitional lumbosacral anatomy (Fig. 29.1).
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Keywords
Anatomy: 33 normal vertebra with 24 presacral segments: 7 cervical, 12 thoracic rib-bearing and 5 lumbar non-rib-bearing. Approximately 5 % of population with variant transitional anatomy with lumbarization of S1 or sacralization of L5 due to partial fusion of transverse process with sacrum, which may predispose to Bertolotti’s syndrome, which can be a source of back pain caused by the transitional lumbosacral anatomy (Fig. 29.1).
X-Ray Imaging
Indications
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Trauma to evaluate for fracture/dislocation s;
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Instability to evaluate for spondylolisthesis and spondylolysis ;
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Low back pain with “red flags” as per American College of Radiology Appropriateness Criteria, including osteoporosis, focal/progressive neurological deficit; >6 weeks symptom duration; age >70; suspected cancer, infection or immunosupression; pain with radiculopathy and surgical or interventional candidate; prior lumbar surgery; cauda equina syndrome.
Technique
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Standard images include anteroposterior (AP), lateral, and coned-down lateral projections of lumbosacral junction.
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Bilateral oblique (“Scotty dog”) views helpful to evaluate for facet arthropathy and for pars interarticularis defects and spondylolysis .
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Lateral views with patient in flexion and extension helpful for evaluating instability and spondylolisthesis (Fig. 29.2).
Evaluation
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Designate number of lumbar vertebra for proper anatomy, evaluate for transitional anatomy;
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Assess bony mineralization and vertebral body heights, evaluate for osteoporosis and fracture ;
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Assess vertebral body alignment for spondylolisthesis as measured by incongruence of the posterior cortices:
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True spondylolisthesis results from a pars interarticularis fracture and spondylolysis (Fig. 29.3);
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Pseudospondylolisthesis , or degenerative spondylolisthesis, results from degenerative disc disease and facet arthropathy without spondylolysis;
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Spondylolisthesis and instability based on measurable changes of horizontal displacements or translation and angular changes between adjacent vertebral bodies between flexion and extension;
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Curvature for normal lumbar lordosis (on lateral view) and degree of scoliosis (on frontal view);
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Intervertebral disc space heights for disc space narrowing and degenerative disc disease and the vertebral endplates for osteophytes and subchondral sclerosis;
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Facet joints to evaluate for osteophytes, subchondral sclerosis, and joint space narrowing in facet arthropathy
CT Imaging
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Provides greater sensitivity with superior bony detailed evaluation of the trabecular and cortical bone as compared to X-rays, particularly in evaluation of fracture healing and characterization of bone tumors;
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Multiplanar reformations allow cross-sectional imaging in coronal, sagittal, and axial planes for evaluation of fractures, spondylolysis , pseudoarthrosis, and spinal canal and neural foraminal bony stenosis, particularly in pre-operative evaluation (Fig. 29.4);
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In the setting of multiple trauma , routine multidetector CT with sagittal and coronal reconstructions is supplanting the role of radiographs;
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Less useful for soft tissue pathologies such as spinal cord or nerve pathology;
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IV contrast can be useful for soft tissue pathology
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Useful if MRI is contraindicated or unavailable;
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Used in conjunction with fluoroscopic-guided myelography for evaluation of disc herniations
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Helpful in evaluation of postoperative bony graft healing and hardware complications
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Static acquisition in supine or prone positioning precludes dynamic or weight-bearing evaluation of lumbar spine.
Suggested Reading
Davis PC, Wippold 2nd FJ, Brunberg JA, et al. ACR appropriateness criteria on low back pain. J Am Coll Radiol. 2009;6(6):401–7.
Leone A, Guglielmi G, Cassar-Pullicino VN, et al. Lumbar intervertebral instability: a review. Radiology. 2007;245(1):62–77.
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Gaviola, G.C., Shah, N.A. (2017). Lumbar Spine Imaging: X-Ray and CT. In: Yong, R., Nguyen, M., Nelson, E., Urman, R. (eds) Pain Medicine. Springer, Cham. https://doi.org/10.1007/978-3-319-43133-8_29
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DOI: https://doi.org/10.1007/978-3-319-43133-8_29
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