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IRIA Kerala in Association with IRIA Kollam presents - Essentials of MRI Spine Report

May 16 | 2:00 PM

Dr. Arif will discuss MRI reporting of the spine with the help of some cases in this informative session by IRIA Kerala city chapter - Kollam. The MRI spine, like the MRI brain, is one of the most commonly requested radiological investigations in modern times. One needs to be adept and uniform in reading images and framing report terminologies. This session would aim to uncover some pearls as well as some pitfalls of spine reporting. Let us brush up on some fantastic concepts and discover some new ones. Join now!

[Music] uh good evening everyone my name is dr tandy and i welcome you all on the behalf of netflix team together today we are gathered here for a very interesting session by iraq uh which would be introduced by dr sarah so i'll be handed handing it over to dr sarah to introduce the speaker and the session dr sarah please take over good evening good evening all uh i welcome you all for a very uh energetic session by dr arif khan so let me introduce dr adip aadhikan he is the associate professor in mukhambika became medical college he has been actively participating in many teaching sessions happening in kerala and he's a very good teacher and i i he also he also has a youtube channel and all the things for teaching classes called indian radiology intervention so i welcome all of you for the wonderful session thank you so much and over to dr okay yes thank you dr shadows for your wonderful introduction you could have said that we worked together for almost a year or more than that and uh okay guys uh we'll start the session and uh the rest of thing we'll continue before that i would like to thank all the organization team of ira dr richard mathieser dr vinod sir and all for giving me this uh opportunity right now and uh also especially thank you dr anishinaiser also and all the organizing team of ira kerala for releasing the sessions and i think in a span of two weeks this is my second session here and that's all i'll try to be very short precise and on the point uh but as it will go as it goes uh let's see okay guys once again um doctor adif khan sir bean uh i'm an assistant professor in department of radio diagnosis in sri mura it's a college in kanekomari district close to kerala and this program is hosted by iri kerala the column chapter is behind this i thank dr vinod sir for that and um dr sharath of course and uh today we are just going to discuss briefly about uh mri's fine reporting um and uh i had a confession to make i tried to invo include the whole spine as a topic but there has been a problem because you take more time so uh i'm sticking to lombard's fine reporting for this session right now and as you know i have a channel called the interventions in youtube you can visit there for more lectures i'll share a qr code at the end of the session if you want and then we'll start now so today's objectives will be uh i've divided into four parts uh first will be we'll be discussing about the introduction part that is the protocols and uh how to which are the different types of imaging sequences and all then we will be going ahead with the reading of acquired images and then we will be trying to do the reporting technologies and which i will be giving you a template uh basically a template an example template if uh like uh in one slide where you where what enroll you should be reporting how and how and you should be done so the reporting terminology will be discussed along with the acquired images session itself the words like bulges and all and if we have time at the end we will be discussing some sample cases as well maybe one month so going in with the protocol so this is one thing i wanted to share with all my fellow radiologists my colleagues and the other students out there see all patients may not be mri compatible especially their bystanders will not be mri combat be aware of that and unlike in the western countries where strict protocols are followed and the people know how to behave properly inside a hospital in india it's a different scenario altogether so beware of uh intrusion into the mris on like the non zone four of mri where you where nobody should end up is other than the patient who has been properly screened for any uh mri hazards okay here mri is not the hazard unlike ct where ct is a radiation hazard here mri is a hazard sorry sorry so here mri itself is not going to cause any problem here the patient himself for herself is the hazard here if at all she is carrying something uh which is uh non-mri compatible for example he or she has an implant where he is carrying some gadgets with her without your knowledge these all things can damage the machine as well as uh cause significant harm to the either the patient or the attending person so be very careful maybe you have seen recent judgments with the delhi court and bombay high court radiologist was made culpable uh because he was his name his just his name was there on that night so that's how law works in our country they first shoot and then they will think so be very careful mri safety is of utmost importance since uh since the dawn of the news like the new decade uh this mri walk-in evaluations has gone up significantly even without any prescriptions or anything people will come directly to you instead of asking x-ray ct or anything they will directly ask for a whole body of money so that is the scene now so these are some things we should be keeping in mind you can't you don't refuse them but you be careful when you are doing evaluation always rule out for metallic implant if of unknown or non mri compatible implants avoid the cases that's it so it is not practically possible but you have to be safe that's what i wanted to share with you so going ahead with our topic here so uh mraf uh uh and um cycle is fine so uh mri reaching this lumbar spine i put the sacral so the planes of imaging are like sagittal axial corona for actual mri lumbar spine most of us would have seen this the first image that the radiographer will take will be a t2 subjective screening of the horse point that will be a t2 image essentially in the cylindrical plane uh modern day machines have something called total imaging metrics if a little bit older generation machine is there you have to take individual parts together like one cervical spine cut one lumbar spine dorsal spine it will cut and then lumbar spine anyway you are going to do t2 in full 5 or 10 to 16 slices then we have t1 weighted images still and d2 fs images in same plane uh same thing goes for axial also to weighted t1 images and in c-spine we use additional gradient echo imaging also and in coronal plane we use stair t2 and t1 and t2 waiter images so mostly all these things are interchangeable according to radiologist demand and need and need of the patient as well so extra imaging sequences which we use to evaluate in this particular times like we can use diffusion weighted images along with adc then you we can use p1 pre and post contrast images t1 ss actually suppress or fat saturate the t1 just should can also be used uh in certain scenarios where you are suspecting a narrow inflammation or an intermediary or a uh so in today's imaging we are sticking to the degenerative disease of spine so these bracket things will not matter much unless you want to evaluate something else so coming to the green part that is the oblique axial that is usually taken for s i joints uh which will be taken in stir two weighted at q1 weighted images and there is something called semi coronal that is the coronal image acquired not actually along the plane of the body it is occurred along the plane of the sacrum that will be like this [Music] so usually coronal images will be taken in this direction in this case we will be taking coronal limit around the plane of the uh cyclone that is a semi-colon it's called semi-coronal it's not the true coroner it's a semi-coronal image okay so just to show you guys that how it is done and uh here uh what i wanted to show you is that very often when you have seen mra before mri image is given to you by your radiographer or technician you will be seeing this black bands here so these are actually the effects of saturation bands what we are attempting here is to improve the image quality by reducing the things which is uh not required in the field so we are creating a rectangular field of view it is called rfov this is called rectangular field of view and using that rectangular field of view you can do the imaging so rectangular field of view we have to create or for both as well as axial sections whatever structures are not required are eliminated from the field of using saturation mass so that is how the images are acquired so this is a saturated p2 image the corresponding axial section of this area is in this so these are all my cases and we can in modern day machines we have something called uh tim which i've already explained earlier it is called total imaging matrix the advantage of this is that you can take after one go you can take the whole spine without changing the surface coil on the anterior aspect so that is one advantage of this so uh it is only for one plane that usually along the frequency recording axis the image quality will be better so you'll be taking satellite so now coming to the important part that is a reading of images so i've listed out essential steps in reading mri images for lumbar spine or any spine in that manner so you can start with a pre-read checklist followed by assessment of the holes fine then assessment of individual this this is actually very debatable i myself follow the assessment of vertibras step before the assessment of diabetes uh but some radiologists who i know myself and cds so they always follow the disc one first and then four other at some point then you have to see the facets neural foramina then coming out of that then you have to roll out any central scalar stenosis which actually can be clubbed with the vertebral assessment as well finally this is uh what i wanted to show you today uh most of the radiologists including me myself i would have missed a couple of times sacrum you see the study asked for you is called not lumbar spine mri it is actually lumbosacral mri with a majority of the consultants who are referring you expect to report like that but uh if they send it as a ls point we have one or two sequences or cuts in this actual week and that's all but if possible you can always image it that's what i wanted to share with you because pathologies will be either disk related or vertical body related and in some cases it will be related to the sacroiliac joint so you have to see the sacroiliac joint whenever it's possible at least one coronal imaging steer uh sequence will do justice the reporting so the pre checklist is nothing but uh having a clinical insight before starting the report so you have to know any uh clinical uh issues the patient has a example if the patient had a surgery prior to the procedure it will be very helpful because you'll be seeing some kind of weird changes in the soft tissue some defects in the bone so those things you have to know otherwise you'll be reporting it as a different stuff so you have to know that and you have to confirm the presence or absence of implants and if it is there you have to consume the presence of a combatable implant like that so uh similarly if at all any previous mri or cp reports or images are available you have to make sure that they have provided you with that for your perusal so that the clinician expects you to compare and give a report 99 of the time that is what they expect so we have to make sure that you have gone through the images as well and then uh what is the advantages of having all these before is like the the there is you you are reducing the chances of having a false negative report significantly so this is important then also this reduces the time of reporting significantly okay now step two is assessment of full spine this is a line die line diagram of the whole spine we will come to the mri image in shortly so what we are assessing is three c's basically that is curvature count and code so the curvature of spine the normal anatomical curvature where whenever we discuss it is our actually a curvature we represent when a patient or a man is standing but in mri you should remember that you are making a patient lie down so there will be changes or of the overall appearance of the curvature or spine one typical example is that very often i have seen reports written as straightening of cervical spine that might not be actual true straightening that is maybe the patient's patient is lying down some support has been given to the head then the head will look straightened up uh and similarly lumbars find some if some support is given it can either go for increased lower doses or it can uh go for uh uh reduced lordosis so uh this uh this actually uh creates a confusion like uh increased orders is reduced so do we speak in anatomic terms we have uh total two sides of uh lordotica and two sites of kyphotic so the two sides of lodotic curve is one is in the cervical spine region and the another one is in the lumbar region and the kyphotic curve is actually seen in the thoracic region as well as in the sample so other things you want to discuss i will come to in details here so the counting of vertebra is a quite important top aspect because very often the if your county techniques are not correct you might miss a level or two so basically what we are doing is we are assessing for transitional vertigo so that we can rule out sacralization of l5 multiply or lumbarization of s1 particular and other uncommon types are also there so this is important mainly because if you are not identified the transition vertebra you might be report reporting a a level higher or lower than actually it is so this can give a wrong clinical impression to the consultant one typical example i'll tell you is you have a sacralized spine so that means this level will be uh this level will be not alpha s1 it will be l4 l5 and you have reported this as uh l5 s1 instead of reporting it as l45 and here some disc bulge and compression is there and the clinician is expecting actually an l4 l5 radiculopathy and you will be reporting it as l phi s one radical i hope you can understand what i just can't wait so that kind of confusions can be avoided and that's one thing and counting uh vertibra is pretty easy when you have a very good technician who is very kind enough to label all these things for you from starting from co2 you should start the count from c2 not c1 2 3 4 5 six seven then comes one two three four five six seven eight nine ten eleven twelve not thirteen again one two three four five so like that you have to come i've seen people counting retro reverse don't do that if if at all there is some segmentation problem as you can see here you can you cannot count all the segments of sacrum here you can only see one two three four but actually there are five segments some joint might not be completely formed so don't do that you count from top to bottom that is always safe okay and even in a labeled image please do come so next entity is uh sacralization of l5 vertebra which i have already told there are two types that is like complete and partial uh so complete cyclization basically what means is that the transverse process of the if for l5 cyclization is there that l5 will be oriented along the axis of this s1 over the satellite segments and there will be uh broadened transverse processes which will be fusing with the s1 segment so this is a same case uh different sections as you can see here you can see a broad and transverse process here same would have been there if you have taken this section also so this is more common complete is more common which occurs around 17 percent of the population and partial means all either one side might be fused so this is an example of a partial cyclization as you can see right side transfers process it was not broadened here only the left transfers process so remained one point here i would like to remind you one point here that is um you have to take correct axial sections a little bit obliquity might plant you in confusion whether that transfers process is broadened in one side or the other especially when there is only partial fusion okay and another point i want to share is that right sacralization only when you can confirm either of these one is complete cyclization is there and other one is you are seeing a broader transfers processor from diffusing with the s1 segment uh because uh many a time there will be something called sacral tilt of l5 vertebra that means the vertical alignment will be having a slight tilt towards l5 will be having a slight tilt towards the cycle segment and you might you can mistake it for a partial fusion or partial cyclization don't don't confuse those things so this there is a classification it's there in wikipedia as well uh it's a very simple classification this is how the normal uh line diagram of a lumbosacral joint looks like very away oriented uh transverse process with good space so in type 1 basically it is unilateral or bilateral hypertrophy if the transverse processes without fusion or articulation type 2 is high unilateral or bilateral hypertrophy with the formation of pseudo articulation there is a pseudo joint for formation type 3 is actually a unilateral or bilateral fusion broadened transits process with fusion and type 4 is actually a little bit confusing uh but to say easily it is like 2a on one side and 3a on the other side so here we have three a on the right side and two a on the left side what basic difference is uh one side it will be fused the other side will be unfused means it is fully there but it is not forming an ankle joint is not used okay so this is cast levy classification of uh cyclization now how to rule out a partial cyclization i already told you you see the transverse process properly if you are able to see two separate transverse processes and which is not uh saying to a joint with the sacral layla then you can say that it is not saturalization partial cyclization so this is a this is a lumbarization where you have an assimilation of s1 lumbar spine so when you count from top to bottom you will have a six lumbar segment vertebrae instead of five as you can see here the afternoon it is one two three four five and six are there this is satellitation therefore not cyclization lumbarization there will be six counting numbers so this is another for our department case uh where a young person came with back pain he had other problems along with uh this uh uh lumbarization of isomer so mind is uh every now and then one or two cases will come to your department uh with the backache and you will find the node as well nothing will be there sometimes you have to check double check whether the patient has a sacralization or lumbarization because that itself can cause curvature problems and pain because of the weight loading differences so now uh the important part of radiology but most of us don't like this reading anatomy so i have a side by side loaded uh one line diagram as well as one mri diagram of the spine so we have a uh like the black shadow portion is the angular fibrosis and angular fibers and the central portion is the nucleus pulposus so analyst fibrosis nucleus pulposus and then we have the canal in the central canal is this portion where you have the thicker sac which will be represented as a dark line in d2 waiter images inside that you will see multiple coda rules and you if you you get uh can we in between i got a message in the screen that now people can see your screen was it not been seen oh no it's completely visible okay okay okay just now i got a pop-up saying that okay so central canal is a and the simple canal can be uh on towards the lateral aspect you can uh this area is actually uh the area corresponding to your physical uh joint so this is that area and this is a numeral parameter so that this is called lateral resist and this is the numeral parameter and you can see an exiting nerve here as here and here as well so then we come to the posterior aspect then i this is a faces joint i'll be showing in a better image in the next sessions but uh just to be sure the the posterior aspect is actually the inferior process of the above vertical and the anterior aspect of the joint is formed by the superior process of the below vector that is if it is l for alpha joint this is l4 and this is alpha this is l4 vertebra and this is l5 and this is just to show you the keyhole appearance of the neural frame in cylindrical images yeah also you can see the faces joints so this is uh this is the like the vertebral levels on the face it's joined together so accessing the individual this uh is the next step which is the important step here because we are checking for this obviously uh and uh normally what we do is we check for two things one is the signal and then next one is the disk morphology this is how a normal disc looks in a uh psychiatrical image and this is how it looks in an axial image we can see a simple clear hyperending area in d2 this is a t2 weighted images titivated image and with the rim of high point density on sand images and the same thing in axial okay so this is the line diagram of the scene so i just wanted to explain everything in one image so that's why i put this case here so disc dissipation basically represents as the nucleus pulposus loses its uh flexibility uh there will be like as the word we use not the dehydration that's the dehydration progresses the t2 signal on the central portion will become lower so that's why we call this this desiccation or dehydrated disc so this is a normal disc with normal uh t2 signal on nucleus pulposus and this is like the desiccated completely desiccated this and this you can report partial dissipation when you come back with the airborne levels signalizing blow uh you can write partial dissipation or complete desiccation on normal so this is the same thing appearing on uh t1 weighted images which has not not much role in uh diagnosing this classification because as you can see all this will have almost the same signal on t1 meter images so next is this morphology uh you can have a normal disk at this with reduced height or and of course lost sick loss of signal and then you have different types of bulges there can be diffuse this bulbs which can sometimes be symmetrical as in this case or it can be asymmetrical or it can be focal dispersed then if you have a focal disc bulge uh there are different types of focal disperse but when while reporting you can report it as either central para central or lateral that's how the terms i follow and that's the terms which you should also try to form that is the central disk well is like exactly in the center of the this other bulge and the parasite region means you can divide the parasite region with two portions the one area which is corresponding to the physical joint is considered as a particular zone and the one area lateral to it it is considered as foraminism that is a foreign zone and outer outer to that that is the lateral pulse it is the extra foramen zone so beyond the neural foramina it is called lateral bulge and then you can also have anterior pelvis also which are not relevant in our discussion today so then we have angular fiber injuries which can be divided as partial or complete partial injury of angular fiber is called fissure and complete injury is called tear so just to show different types of bulges this is a normal appearing disc with the posterior concavity anterior anterior convexity this is how the disc will look here you can see a posterior central this punch and also there is a lateral component lateral disc bulge also is there in this particular case and this is an uh paracentral disc bulge this is not of the lumbar uh spine level this is a cervical spine image i just wanted to show you how it looks uh there also it looks same so and here in the lumbar spine level this is a case i just wanted to discuss the and correlate with the image which i've just shown you so here what you can see is the central zone is free there is no central display the entire disk is bulged along the para central zone okay so that is the para simple display this air with the lateral component is also there so here you can see there is significant narrowing of the [Music] area at the sub articular zone or the neural creases and even the neural foramina is also narrowed so this pro this will be definitely compressing the nerve as well as may be impinging onto the excited nerve also so uh next step i've already discussed that is angular fischer tear and in the intravertible herniation so i've just color coded stuff to make it easier uh so the orange area where you have only partial involvement of the endless fibrosis this is how a fischer looks like when it is completely drawn and invariably your whatever nucleus purposes is there that will also try to come out of this forming either protrusion or exclusion uh that is called an angular tail then you have uh in intravertible herniations which we report as small snores where you have indentation on the vertical body creating that so here in this image you can see uh this is a focal posterior angular angular tear in an axial image and this is how it looks in a subjective image and next step is to assess for this now we have checked this bulge is there so we have reported it as there is a posterior central or posterior para central right or left this bulge is there and before not there is any angular air is there so a disc bulge with an angular tail is essential for this to happen so you should have extrusion or protrusion not necessary can occur so what do you mean by an extruded disc extruder disc is a disc where this when when you report extruded distance like when you have a broad base like your base will be broader the opening will be broad and when you have a disk extrusion the neck will be narrow so a protruder and x or an extruder this can cause either cranial or model migration also and it can undergo sequestration when you say discuss being sequestrated when it loses its communication with with the you know this body that is a individual this body it has losses communication now this thing is very free it can move up or down depending upon the scenario so just to show in images how this protrusions look like so here you can see this is this protrusion with where you can see a bulge in the central and parasimal region left the parasitic region and you can see the base is wider than the tip of the bulge so this is kind of considered as protrusion so here also it is there same it is more like a central location and here is actually an example of paracentral uh dis protrusion so in this particular image i wanted to show you one more thing this is an example for a cranial migration so here you can see what what you see is that already the disc has protruded out and it has tilted towards the cranial side so this represents a cranial migration and once if it gets disconnected from this portion that will come later so regarding this extrusion what happens is that in this actual image the blue line actually represents the remnant of the angular and this fibrosis and here is a gap here there is a gap in this particular portion and through which this this guys are needed so this is an example for extrusion where there is a narrow defect with the broad tip the tip should be broader than the defect so this is this extrusion so this is another example here uh where you have a central angular layer and there is a disc extrusion here and here in this case this example you can see that this components are going down so in this case if i am reporting i have reported this case as a central tear with uh disk exclusion and caudal migration quarter means towards the food it is going down so it has to be reported as coral migration so this is cranial migration and this protrusion this is caudal migration and this exclusion okay now coming to this sequestration what happens here is uh as i mentioned earlier that this component has completely detached itself from the uh individual disk level and it has gone uh beyond the margins of the uh this um interpretable disk which this is actually erasing from this particular individual disk that is l3 l4 individually this can just migrate gradient so because you can see the other way other this guy is having a smooth round margin here here some connectivity is apparently there but it is not that this is exploded completely so in this scenario you can apply uh t1 fs post contrast image uh just to rule out uh any so this will cause very here you can see uh the t1 fs images there is peripheral cross contrast enhancement without the enhancement of the component per se so this confirms the diagnosis and uh one important thing i wanted to share with you now is uh the the you the use of migrated this actually the reason i put it here is when i put the same topic in the youtube channel long back somebody has asked about this but back then i couldn't explain it because of time issues and it's simple you can put migration for both sequestration as well as perturbation or execution if static has migrated crazily in an extruded disc you can write it as explosion with cranial migration if the discus sequestrated cranially you can write it as a sequestration cranially like that from the level of combination so there is no problem it is interchangeable it can be used interchangeably just to show where the mythology is so step four is the assessment of vertebra uh okay step four is will be the assessment of vertebra uh so what we are assessing here is generally uh the height of the vertebra the signal changes and uh even alignment like analysis and electrolysis these are the things which we have to essentially look uh in spine mri okay so this is just an example of how uh a change in marrow will look like so this is actually t1 weighted images this is a t2 weighted size t1 sat images and t2 size images where you can see a well-defined uh t2 hyper t1 hyperintense signal area and e2 hyperion signal area as well the same a lesion which on steer will show reduce the signal so this is a telltale imaging uh evidence of an imaging hyper on t1 hyper on t2 because of fat is there it will get response there so this is 90 percent imaging and in this image i wanted to show you some other things also you can see here uh in a there is a small snort in this level of vertebra which is seen here also and there are signal change of the end plates so the end plate signal changes what does it represent n plate signal changes uh we will be discussing in next in next image just again so those are classified as the generative input changes are classified under the memory type changes so basically it is a degenerative and inflammatory changes involving vertical end plates and not just inverted fluoride is seen on mri the imaging sequences which we use to assess our p1 and t2 weighted images so there are three types in type 1 which is the acute phase or the edema phase you will be having a hyper intense signal on uh t2 weighted images with low signal on t1 major images in the intermediate phase where we will have basically fatty replacement of the marrow um they will have hyperintense signal on both g1 and t2 and in the late phase that is a type three where will be sclerosis you will have low signal on both g1 and t2 so these changes so now i'll go back to the slide these changes might affect in their end plate or can be even a part of the implant as you can see here so what it essentially means is it is actually the area of osteel injury happens while you are while you're just getting compressed against the vertigra so in this case you can see there is an intravertible hermitian or the schmorze knots in the anterior aspect with high-performance signal on the anterior end plate of both uh l5 vertebra on both t1 by 83 means 728 if you look closer you can see a similar change happen here also this is actually uh l3 vertical body you can see here also there is a irregularity in the upper end plate anteriorly but here as you can see the signal is not the right it is reduced here similarly on t1 also it is reduced so in the same so image we are seeing a type 2 as well as a type 3 change of mode hope you would understand that okay moving ahead so there is some there is a study which says that there is actual correlation between lower back pain and body changes especially the type one body changes that is the acute phase where the injury had happened then comes the vertical height and alignment i'm not going into theory of this i'm just explaining everything in this one particular image so here what i wanted to say is that the height and alignment basically you are looking for a compression fractures and secondary kyphosis or scoliosis is due to those convection fractures so as you can see here all that these two fractures have different signals in uh steer images so this one here is having a reduced signal on t1 weighted images this is the t1 weighted images and this one here is having a relatively high signal on t1 weighted images this is in the dorsals finder in lumbar spine levels similarly we are changing uh intermediate signal or low signal on t1 images and uh uh high signal on still images so this actually represents an acute fracture so these these these two and these two represents accurate fraction meanwhile you can see remaining of this fractures on the lumbar spine here shows actually the expression of the l4 and l5 shows very low signal on still images this represents old fractures okay so this is a way of determining between an acute fracture old fracture in if the fracture is acute it will have a high signal on uh stir images and low signal not even weighted images if the fracture is chronic that is all in order fraction it will have a high signal on t2 and b1 but low signal still remains so now coming to the next topic of the vertebral body estimate that is assessment of alignment so we have uh something called spondylolisthesis what essentially is this is that it is a anterior or posterior uh subluxation of a vertebra or another vertical that is a simplest explanation there so the most common area of spondylolisthesis in our lumbar cycle region is between the l5 and s1 vertebra and in degenerative uh spondylolisthesis invariably there will be spondylolysis also so that means there is a damage to the faces due to chronic arthropathy and that will result in anterior uh or posterior subluxation so you we can grade it uh the grading is quite simple uh whichever vertebra is below if it is l four l five uh spondylosis of l four over alpha you have to divide this surface into four parts now here in this example they have actually shown alpha s one subluxation that is condylar android distances so you have to divide that into four parts each part counts a 25 value so if it is 0 to 25 percent it is grade 1 25 to 50 it is great to 50 to 75 it is great three uh 75 to 100 it is grade four if it is completely off the cliff like this there's fallen off the cliff uh which is the surface of the sacrum then it is grade five or we call it as spondylotosis quandaro ptosis okay i'll show you an example here you can see uh this is the subjective image of a spine where you can see a grade three androlystosis so in this patient this is my personal case here and in this patient we had he had a vesicle uh arthropody also and there was formula lysis in this case so this is another case uh from uh uh radiographics and uh in this actually there is l4 over l5 there is an anterior subluxation of l4 or l5 and many times my residence or um my juniors are asking me this question like why it is always said uh android so why can't it be the lower when people are going beyond actually here what the alignment is fixed alignment is the lower part vertebra here in this case and the non-fixed alignment is in the superior vertebra so that's why we are saying uh subluxation of l4 over l5 so the l4 is the one vertebra which is moving out of plane this is still in plane so i take a point now is in majority of the spinal canal narrowing associated with spondylolisthesis uh degenerative spondylosis will be a main factor meanwhile in other if there is no degenerative spondylosis uh either canal will remain either normal or it will remain just a technical point and whenever you have canal narrowing in this kind this scenario you should measure at the disc level at the disc level as well as at the vertical body level also now uh again the same image back to it so just to show you the neural thesis and you will forget here and uh so now we have to go for the assessment of facets and neural foramina that is a step five and uh in facet assessment we are basically looking at facial arthropathy in our case today so what what and all things you will see start properly so in a normal facet when you view in sagittal profile will have a clear t2 signal between the faces okay so that is important the posterior one will be the uh facial joint of the inferior facet of the above vertebra and the anterior one will be the superior face of the below vector as you can see here nicely so same vertebra when you come down here this is the posterior process of that vertebra this is l3 i guess l3 yeah l3 vertebra and this is l4 vertebra superior so like that you will see so in this case you can see this is normal appearance and here the signal has reduced a little bit so this is a sign of early arthropods as in this case actually image so along with that you can see we have a diffuse spell with a posterior bulge as well so [Music] destroyed completely and invariably there will be a spondylolysis as well here there will be there will be damage to the particular uh joints and there will be uh if you see the image in cd that will be clear fracture will be there at the facital level and uh later stages this can cause subluxation anterior uh distances of this vertical so this is actually quite interesting because when we do dorsal spine screening this is one area which most of us overlook you should always see the facets for any hypertrophy so in this case this actually it was a case which came for lumbar spine assessment with the whole spine speeding we instantly saw very much hypertrophy and ossified uh facet of uh on the left side which was causing severe narrowing of the left immoral foramen and this patient had a typical complaint of uh one of the dermatom's pain was there for him so this is one finding you have to be careful we have to check all levels if possible and it can be seen in size images like this this is a normal keyboard sign this is the keyhole sign being lost so this is again another example another tv show look is the ligament of flavor here you can see this is the ligament of flavor uh in facial arthropody invariably in most patients of above 40 45 years of age with face cloth this will be thickened this is like a supportive ligament so now one entity i want to discuss is uh discuss first the face of joint synovial cyst so what essentially it represent that due to the increased pressure and inflammation the fluid whatever is retained within the cyanobeam will get pushed either laterally or into the joint space that's in the uh the physical so what happens is this is how it looks in mri uh it will be a hyper index signal system which which has signal intensity similar to that of uh fluid water so this is the synovial cyst which is actually narrowing the neural rhesus uh and which will compress the exiting the root at this level so the diagrammatic representation of the same so this you can actually correlate with your baker system the knee joint both those are similar kind of cis but here it is occurring erasing from the synovial joint of the preset so the same lesion in sagittal profile you will see like this you will be thinking it has an extraordinary mass face of fine lesion but actually this will give you more clearer picture and in these kind of scenarios when you see such a lesion you should uh try to take 3d images 3d means thinner images signal cuts will show definite communication between the the system or the lesion with the joint that will give you a much better clue and as you can see here there is a significant uh irregularity of the phase it will join even the central signal is still there this also says it is going from moderate level arthropod is there then comes the developer where the changes is from keyhole appearance to slit so basically a normal neural foramina will have all areas surrounded by csf fluid so this is the exiting neurotux at this level you should remember this the narrow route occupies the upper half of the neural parameter not the lower half so this is like mild narrowing and even in this stage there will not be any significant compression of the nerve but from moderate narrowing onwards there will be significant uh clinical effects and in severe stenosis there will be complete absence of this halo you won't be able to see this halo at all so there are uh literatures grading this as grade one two and three that is basically mild moderate and severe you can follow that if you want then next step is to rule out central canal stenosis which is of course you will be checking while you're doing the bulge assessment so here in this case you can see uh there is a significant narrowing of the canal at the disc level so if i am reporting this particular case now i will be reporting first i will be reporting that this is a diffuse this bulge where there is a significant uh narrowing of the symbol canal at the level of this and i'll be mentioning i mean i will be measuring it both in size and axial plane and i will be giving it this in brackets like that the canal at this level measures this mm or mm in maximum androphostical dimension bracket close so this will give a direct idea about how much narrowing has happened after this level so you can add on to other disk levels in the below or description so that they will have an idea about above and below what was the actual diameter of the canal so this is again the same image i showed you earlier i just put it again here also you can see how much the central canals is there okay and here also there is bilateral ligament of hypertrophies there there is even uh face it will join arthropods also with the irregularity so this is uh the last step the step seven the assessment of sacrum and si joint uh so uh sacrum you have to acquire the image in a plane like this as you can see i have earlier mentioned that this is somewhat like an uh semi coronal image not the true coronal which would be like this here it is taken in a semi coronal uh question and in this position when you acquire uh you will get images like this so this is a our department keys again and you can see uh clear this is a this is a t1 weighted image and you can see clear p1 hyper fat on the sacroiliac joints so other images which you can take is t1 weighted images and still images in both same planes and if at all you are finding any pathology or the concept and the referring clinician has asked you that they are suspecting sacroiliac please please do image it properly you take oblique axial as well and do if you are suspecting uh acute sacroiliac which is not picked up in general routine imaging you have to give some contrast iv contrast and take p1 fs images for both but giving contrast is a huge headache for radioactive wherever you practice you have to get the permission from the patient consultant because of the cost involvement so instead of that you can even image it with uh still uh proper axial and t2 also it's fine now uh these are the other images how it looks and uh how a normal sacroiliac looks in the coronal stair image you can see the fat is completely suppressed this is how it should look there should not be any spec of hyperintensity in the sacroiliac joints so again uh the this is a t1 image axial section is a two this is a two axis you can see axial of the oblique corona you can see the fracture so now just briefly about typical mri features of saccharomyelitis the first and foremost feature will be uh inflamed sacroiliac joint which will be high permanence on still images and this is on the right hand side we have is a sphere corona on the left hand side what we have is a force contrast even fs corona so in the right hand side we are seeing uh increased signal within the joint space and in uh post quantum study you are seeing enhancement as well as ostitis that is like enhancement of that this is bond planning also so that is uh the changes you are expecting followed by these images where we can see the similar changes this is again still coronal and postponed study this somewhat follows each other in respective images only in the later phases uh where we have a significant bond involvement the enhancements start changing because the area closer to the joint will become less and less enhancing and the outside portion will still continue to enhance so this is a towards the end stage where you have a significant signal loss on the particular surfaces and follow with erosions you can see your ocean the surfaces are irregular so next thing to check these are all miscellaneous parts these things to checks are the para spinal muscles uh please do look for this because if you are assessing a degenerative uh disc disease in a patient of more than 50 years of age there might be significant atrophy of the parasite muscles you remember because you would have already gone through shoulder mri reporting uh which has been conducted by iarioli er in recent or in the past and those the same person's grading is there from 0 to 4 grade 0 is normal grade 1 is very minimal streaks of fat there is more amount of fat but more than 50 percent there is still muscular tissue there is a grade 3 is 50 50 grade 4 is more than 60 uh will be atrophied so you can see the imaging clearly this is actually all images of t2 actually images you you can use t1 images as well to see this so but the grading is different defined in the d1 axial mris okay so we understood so the most important part of today's discussion the checklist which you should go through before giving your report and i think i have described uh all the terminologies along with the topics which we have just now covered uh so we're going ahead with the structured reporting so in any mri report do mention your these two things one is the clinical detail of the patient and the second one is the protocol you should mention that what all imaging sequences you have seen and what are provided for you to report they might have taken n number of sequences and send you some images only so you have to tell whatever protocols has been used to image the patient okay then second comes is the whole spine assessment which i've already mentioned button double things to see rule out lumbarization cyclization the curve curve appearance weather straightened increased and be very guarded when you are reporting curve straightening and all invariably it might be because of positional thing uh that's another story and then we have uh vital body height then the signal changes or any other abnormalities this will form the indra of the report then you have to mention of course you have to mention any post-operative changes like laminate fixed status etc and followed by uh the code yeah of course you have to mention the ending of code whether it ends at l1 or not uh whether what the status of coda equinox phylum terminally narrows all those things you have to mention then you come to the disk problem so after describing about the height and signal you can switch to explaining the disc pathology see ideally uh uh we should follow a protocol where you are described individual this so if you are describing lumbar spine you have l1 l2 till alpha s1 level or if you have a lumbarization you have to report s1 is true level as well so that is that much early so each level you have to describe in a row and then you just give descriptions like no significant disperse no central canastinosis or new neural parameters for there is mild viscerals what type of bulge it is uh whether angular tear is there or not if there is there whether there is protrusion or exclusion is there or not and then uh their comment about the single canal stenosis if present or not so like those all things should come at each level so this this should con be that and an additional findings like face it joint morphology ligament flare hypertrophy and neural foramen stenosis and the compression of each roots should be mentioned at each levels okay then uh finally about sacrum and sacroiliac joint which we have already explained earlier then if you you have to make a brief mention about the paraspinal muscles and pelvic muscle pelvic muscle especially the piriformis we'll come to that shortly then we have miscellaneous findings like very often we have seen cases like this a couple of months back we had uh even we had incidentally picked up an ovarian system one young lady uh which actually was a which that one they underwent an mri pelvis contrast and all and which which was created as uh higher higher order overacts category and uh posterophilic team is assisted you know system i think yeah a very insisted and similarly when you see such findings you just mention it make a mention of it because uh later on it will be helpful for the patient and yourself also okay and additional things which you have to look will be the soyas muscle and of course iota we had achieved long back uh where uh we instantly picked up an io dissection iot resection in uh mri of lumbar spine so i'll come to that shortly so this actually ends the talk here i have a couple of interesting uh findings to share with you okay so the miscellaneous is just like a spotter because we all love supporters now right now after that extensive theory class you would be sleeping now this just reaching your memory once so the first one here is i can try to identify this so this is here is a t2 hyperindustic area inside this uh spinal canal and here also it's a different case of the same pathology so this is basically a perineurosis or it's also called a star losses there is a ah there is a very good article about carlos's uh classifications and all you can go through it i have mentioned it in the bibliography i'll share you share it with you guys so talos are essentially perineurosis so um in general they will cause a slight widening of the canal and all that's that's one thing and rarely causes significant conversion then we have been discussing this intermittently about post-op changes you have to be very sure of this so here you can see a laminated laminectomy defect on one side of the vertebra so this i have to be very very careful about those things diamond acting in effect here you can see that there is a absent vertebral component here lamina is removed this was done for a painful back and the surgeon has removed the laminate to reduce the pressure and in some cases where especially you have heard about a syndrome called the failed back syndrome where the patient develops keeps on continuing to develop back pain even after a surgery so this happens uh in numerous causes one of the causes is uh when there is increased csr pressure there might be leakage like this so you can see the csf has been leaking out and it has been forming a pool around the defect and into the interest muscles if this is actually the centrifugal approach side and it is very easy for uh this thing to dissect the csf dissect through that spaces so this is one example uh not common it's taken from one of the journals so this is again one another finding which you all should be aware of this is called the empty sac sign so empty sac sign what happens here is uh it is a sequelae to arachnoiditis adhesive node it is what happens is that all the phylum terminal in the roots will get attached to the entire uh checkered sack you can see slight beginning of the thinking second period and here if you look carefully you can see there is a defect here so this is one of the complications immediate complications post-op after laminectomy or micro dystectomy some people will develop this and this is a self limiting condition or you can treat it with antibiotics and steroids and it will come down so this is one finding i wanted to share it this is how it looks inside item you can see up till here you can you are able to trace some nerves within the canal and after that you are not able to trace it so this is uh way out of the topic of discussion today but i just wanted to show you uh other aspects where you can see vertebral body destruction with pre vertical and epidural components here with significant compression of the code and this was a case of biogenic spondylodisciplus so you can see the t1 plus contrast surface image showing peripheral enhancement as well this is axial t2 and this is axis v1 so this is ah this one is quite interesting finding i know maybe three of would be annoying so this comes as a differential for a non-enhancing non-energy cf signal intensity area in the coda equinox so this is actually a ventricular terminalis it's a normal variant not so uh dangerous uh it's like a touch me not kind of thing but when you see this it you might confuse it as a maybe a focal syringe or maybe an intra metallurgion in such scenarios you can just give a t1s contrast images and you will see it is non-enhancing so this is what i was talking earlier piriformis muscle hypertrophy and pyruvate syndrome see if you have a patient with a significant unilateral limb pain that is especially hip joint pain or typing you should always try to rule out this thing so what happened here is this is the left side and pi reform is muscle and this is the right side from this muscle there is significant hypertrophy of right side performance muscle so this itself will cause compression of the sciatic nerve and relative secondary pain so hypertrophied piriformis and bioform is synthetic so as i mentioned earlier fibroid very commonly you can pick up some most of the ladies of certain age group and you should make a mention of it even though if you are not describing it too much you can make a mention of it and this is our case of the day and this is actually not our case unfortunately i don't have the image for that this is a case from an online journal and you can see uh the dojo sign like the japanese dojo sign you have a black and white inside the iota so what basically this is this is an ionic dissection the normal flowing side will have a flow void and the slowly flowing side will have hyperintense signal of t to eight limits so i think that's all for today these are the references you can go through it i'll share it in the description and uh [Music] one interesting article is there i think we all should go through this article uh this is our about communication between radiologist and clinician i'll share it in the chat box you can share it with the attendees and this is me you can scan the qr code if you want to follow me that's all manner thank you thank you really you're a great teacher i felt when you were teaching each slide i felt the teacher in you yeah it was very good nice to hear all the verdicts actually i couldn't come from the initial part because i had some problem here but now all the other i could uh hear it very nicely and it was going into a brain when you were talking each and every slide was very wonderful i liked it so much so good it uh it will be better very good for the residents also who are start reporting the mri spine really really wonderful okay thank you so much [Music] i was sitting and listening to all the talk about the points which i was telling this is really useful for the residents if they are listening to it okay we have uh dr other we have a few questions from the viewers okay you have already covered it dr dave ravishankar has asked do you comment on uterus incidental findings which we have already shown in the last uh yeah yeah we will come in yes we should come in actually this past defect always associated with spondylolisthesis yeah is the past defect associated with spondylolisthesis yeah majority of cases of degenerative spondylosis spondylosis is actually associated with that so we will be reporting it as degenerative spondylosis with spondylolysis and spondylolysis that will be like so much of this but it is the correct way to represent it all right doctor thank you so much and we would like to thank you on behalf of kulam city chapter and kerala for the wonderful talk and it was very informative and it was touching the basics a lot so that it was a very refreshing class for all of us who were here who were still reporting spine we could just grab a lot of things from the talk and thank you so much and we appreciate uh more such lectures from him okay thank you and thank you man thank you thank you so much yeah thank you everyone i think uh i thank tanvi from netflix uh for her wonderful support to this and your whole team has been uh doing that uh since uh we have scala area started hope it will continue soon like the same way yeah thank you we appreciate it that's it thank you so much

BEING ATTENDED BY

Dr. Sasikanth Reddy & 607 others

SPEAKERS

dr. Arif Khan Sainudeen

Dr. Arif Khan Sainudeen

MD EDIR DICRI,Associate Professor, Department OF Radiodiagnosis, Sree Mookambika Institute of Medical Science,u lasekharam, Nagercoil

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dr. Arif Khan Sainudeen

Dr. Arif Khan Sainudeen

MD EDIR DICRI,Associate Professor, Department...

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