ROBERTO CARTOLARI U.O.D. DI Neuroradiologia Ospedale “Belcolle” Viterbo – Italy Servizio di Radiologia Ospedale “S. Giovanni” – EOC Bellinzona - Switzerland The Axial Loaded Imaging of the Lumbar Spine 18 Years After. Is It Still a Valuable Examination?
AL-CT In 1992 the idea of Axial Loading
AL-CT Newton’s third law of Conservation of the Momentum
AL-CT Newton’s third law of Conservation of the Momentum
NON-PATHOLOGIC MOTION PATTERN REFERENCE MODEL OF THE SPINE UNDER A PURE AXIAL LOAD
The Axial Loader is a non-ferromagnetic/x-Ray transparent device
AL-CT TECHNIQUE Basal/AL Volumetric acquisition (L2-L3/S1) MPR (Sagittal plane) 3D SSD Basal/AL images cine-loop
AL-MRI TECHNIQUE Basal acquisition (Sag T1w, Sag T2w, Ax T2w) AL Volumetric acquisition (Sag T1w, Sag T2w, Ax T2w) Basal/AL images cine-loop
Axial ImagesSagittal Images3D Images
REMEMBER !!! only axial loading (the simplest work) no motion is superimposed the Patient is SUPINE (it’ s not true orthostatism) AL-CT/MRI
REMEMBER !!! all the findings are REAL (no distortion artifacts) AL-CT/MRI
AL-CT/MRI FINDINGS CLINICAL SIGN !!! > 90% Patients referred partial to total recurrence of their symptoms during axial loading
AL-CT/MRI: WHEN? THE CLINICAL PICTURE DOESN’ T MATCH THE BASIC IMAGING (X-RAY, CT, MRI)
AL-CT/MRI FINDINGS Elementary Dynamic Modifications Intervertebral Disc Modifications Intervertebral Disc Modifications Alterations of Intersomatic Relationships Alterations of Intersomatic Relationships Alteration in Relationships of Articular Processes Alteration in Relationships of Articular Processes Narrowing of Spinal Neural Foramina Narrowing of Spinal Neural Foramina Thickening of Ligamenta Flava Thickening of Ligamenta Flava Narrowing of Interspinous Spaces and Hypermobility of the Spinous Processes Narrowing of Interspinous Spaces and Hypermobility of the Spinous Processes
THE “PARADOXICAL MOTION”
THE “DISC VACUUM SIGN” (“telescoping spine” – J.R.Jinkins, 2002 )
THE “ARTICULAR VACUUM SIGN” (CT)/DISPLACEMENT OF INTRARTICULAR FLUID (MRI)
THE “FUNCTIONAL STENOSIS” (disc protrusion & yellow ligaments thickening & degenerative listhesis)
THE DISC HERNIATION
THE COMPLEX DYNAMIC MODIFICATIONS (CDMs) Stereotyped sequences of EDMs in response to axial loading
CDMsBasal studies Plain FilmsAL studiesInstability grade CDM1- L4 facet underslipping - Narrowing L4-L5 (disc) interspinous space - Conserved L5-S1 disc space - Further L4 facet underslipping - Further narrowing L4-L5 space - Anterior L4 translation - L5 paradoxical motion Grade 1 CDM2- L4, L5 facet underslipping - Narrowing of L4-L5 and L5-S1 and spinous spaces - Further facet underslipping - Further disc and spinous spaces narrowing - Anterior translation of L4 (<) Grade 2 CDM3- As CDM2, plus: - Degenerative listhesis (>) - often disc and articular vacuum phenomenon - Further disc space narrowing - Increment of listhesis - vacuum disappearing (Vacuum Sign) Grade 3 CDM4- Lysis and listhesis of L5 (L4) - Underslipping of L4 inferior facets - Narrowing of interspinous spaces - Widening of lysis and increment of listhesis - Wedging of L4 inferior facets into the lysis Grade 4A Grade 4B
CDM-1
CDM-2
CDM-3
CDM-OCDM-1CDM-2CDM-3 As one of the components of the spine fails for any reason (infection, trauma, degenerative changes, …), a stereotyped series of actions occur which lead to a cascade series of alterations in a sort of “domino effect”
The “DOMINO EFFECT”
modello CARTOLARI
AL-MRI CDM4
FONAR rMRI/pMRI/kMRI J.R.Jinkins – 1999/2000
G- SCAN G- SCAN
pMRI kMRI
At present no comparative studies between AL and rMRI/pMRI/kMRI
AL-CT OF THE OPERATED SPINE
AL-CT/AL-MRI are relatively invasive examinations (X-Rays) moderately time-consuming procedures
AL-CT/AL-MRI are powerful diagnostic tools to visualize the possible alterations in the distribution of the vectorial lumbar pathways after axial loading allow a good visualization of the response of any part of the FSU to axial loading
AL-MRI vs AL-CT
Less invasive (no X-Rays)
AL-MRI vs AL-CT Less invasive (no X-Rays) Better tissue contrast
AL-MRI vs AL-CT Less invasive (no X-Rays) Better tissue contrast Wider FOV
AL-MRI vs AL-CT Less invasive (no X-Rays) Better tissue contrast
AL-CT vs AL-MRI Better bone structures definition
AL-CT vs AL-MRI Better bone structures definition Better evaluation of complex spatial instabilities (3D)
AL-CT vs AL-MRI Better bone structures definition Better evaluation of complex spatial instabilities (3D) Easier evaluation of articular “micro-movements”
AL-CT vs AL-MRI Better bone structures definition Better evaluation of complex spatial instabilities (3D) Easier evaluation of articular “micro- movements” Shorter acquisition time (better Patient’s compliance)
AL-MRI: indications
Younger Patients
AL-MRI: indications Younger Patients Early stages instability
AL-CT: indications Older Patients
AL-CT: indications Older Patients Previously operated Patients (more complex instability patterns)
AL-CT: indications Older Patients Previously operated Patients (more complex instability patterns) Late stages instability
AL-CT: indications Older Patients Previously operated Patients (more complex instability patterns) Late stages instability AL-MRI gives no or little informations
CONCLUSIONS AL-CT AL-CT: Clearly image the operated spine Allows the observation of any intersegmental motion Allows the analysis of the ways the operated spine dissipates vectorial forces Directly evaluate the way the spine devices work First choice examination in FBSS
THANK YOU FOR YOUR ATTENTION