1. Radiologic Evaluation of Musculoskeletal Dİsorders

2. Keys to Success in Radiology
Know what to order
Know what a complete optimal imaging series is and don’t accept less
Read by check list
Know the common lesions
Know the commonly MISSED lesions

3. The Musculoskeletal System
Bones
Joints
Muscles
Ligaments
Tendons
Soft tissues

4. Cervical Thoracic Lumbar-sacral
The Spine
Cervical
Thoracic
Lumbar-sacral

5. Plain Film Check List BONES JOINTS
SOFT TISSUES: the ligaments, tendons, muscles, skin and subcutaneous tissues all blend together to give one uniform density

6. Plain Films The most common imaging modality
Definitive for many conditions
A good screen for many others

7. Plain film: Cervical The LATERAL provides most of the information
Look for malalignment, fractures, distraction, destruction, degenerative changes

8. Plain Film: Thoracic and Lumbar
Same check list as for cervical spine

9. Cervical Spine AP view

10. Cervical Spine Lateral View

11. Cervical Spine Oblique View

12. Lumbar Spine AP View

13. Lumbar Spine-Lateral View

14. Spine Kyphosis, scoliosis or kyphoscoliosis: Squared vertebral bodies
Collapse or flattening of one or more vertebrae
Aseptic necrosis, fracture, metastasis, osteomyelitis, osteoporosis
Vertebral pedicle erosion or destruction:
Bening bone tumor, granulomatous disease, metastasis,

15. Resim koy

16. Differential diagnosis of localized lesions of spine
Block vertebra: fusion of two or more vertebral bodies:
Variable grades of blocking from isolated hypoplasia of the intervertebral disk to complete fusion of bodies.
Decreased diameter of vertebrae at the side of segmentation defect, concavity of the anterior aspect of the block.

17. Blok vertebra

18. Spondylolisthesis:
Anterior slipping of one vertebral body on its subjacent neighbor while the posterior portions stay behind; is usually secondary to bilateral defects of pars interarticularis, called spondylolisis.
Spondylolysis is best demonstrated in oblique films.It may be a congenital failure of ossification or more likely traumatic, either an acute or a fatigue fracture.

19. Spondilolizis
Anterolisthesis of
C6 on C7

20. Spine Imaging Guidelines
1. Uncomplicated LBP usually self-limited, requires no imaging
2. Consider imaging if:
Trauma
Cancer
Immunocompromise / suspected infection
Elderly / osteoporosis
Significant neurologic signs / symptoms
3. Back pain with signs / symptoms of spinal stenosis or radiculopathy, no trauma:
Start with MRI; use CT if:
Question regarding bones or surgical (fusion) hardware
Resolve questions / solve problems on MRI (typically use CT myelography)
MRI contraindicated

21. 7. Indications for IV contrast in MRI:
4. Begin with plain films for trauma; CT to solve problems or to detail known
fractures; MRI to evaluate soft-tissue injury (ligament disruption, cord contusion)
5. MRI for sx of radiculopathy, cauda equina syn, cord compression, myelopathy
6. Fusion hardware is safe for MRI but may degrade image quality; still worth a try
7. Indications for IV contrast in MRI:
Tumor, infection, inflammation (myelitis), any cord lesion
Post-op L-spine (discriminate residual/recurrent disk herniation from scar)
8. Emergent or scheduled? Emergent only if immediate surgical or radiation therapy decision needed (e.g. cord compression, cauda equina syndrome)
9. Difficult to image entire spine in detail; target study to likely level of pathology
10. CT chest/abdomen/pelvis includes T-L spine (no need to rescan trauma pts*)
* If image data still on scanner (24-48 hours)

22. Spine pathology Trauma Degenerative disease Tumors and other masses
Inflammation and infection
Vascular disorders
Congenital anomalies

23. Confusing “Spondy-” Terminology
Spondylosis = “spondylosis deformans” = degenerative spine
Spondylitis = inflamed spine (e.g. ankylosing, pyogenic, etc.)
Spondylolysis = chronic fracture of pars interarticularis with
nonunion (“pars defect”)
Spondylolisthesis = anterior slippage of vertebra typically
resulting from bilateral pars defects
Pseudospondylolisthesis = “degenerative spondylolisthesis”
(spondylolisthesis resulting from degenerative disease rather
than pars defects)

24. Inflammatory lesions:
Pyogenic vertebral spondylitis:
Disk space narrowing
Loss of the normally sharp adjacent subchondral plates
Areas of cortical demineralization
Destruction of the vertebral body, possibly collapse
Sclerotic new bone formation, sometime spontaneous fusion.

25. Spondilit

26. Spinal tuberculosis:
Involvement of the thoracolumbar or midthoracic spine, osteoporosis, large paravertebral abcess relative to the amount of bone destruction, narrowing of one or more disk spaces after erosion of endplates, anterior compression of adjacent vertebra
Involvment of three or more vertebral bodies, skip lesions in the spine, a large or calcified paraspinal mass

27. Spinal tbc

28. DISH (Diffuse idiopathic skeletal hyperostosis):
Disk degeneration:
The disk space is narrower than usual. Later the adjacent end-plates may become sclerotic and osteophytes develop.
A steak of gas within the disk space is indicative of the disk degeneration
DISH (Diffuse idiopathic skeletal hyperostosis):
Flowing calcification and ossification along the anterolateral aspects of 4 or more contiuous vertebral bodies

30. Rheumatoid arthritis Change in order of apperance:
Joint effusion and periarticular edema
Periarticular osteoporosis
Joint space narrowing
Marginal erosions, pseudocysts
Compressive erosions
Subluxation and malalignment of joints, ulnar deviation, and flexion deformities in fingers and toes
Bony ankylosis, representing the end stage

32. Ankylosing spondylitis-1
Sacroiliac joints are bilaterally, symmetrically affected.
Initially loss of definition of joint margins followed by
Osteoporosis or sclerosis
Erosion and narrowing of joint space
Ankylosis

34. Ankylosing spondylitis-2
Radiographic Findings:
• SI Joint narrowing—Symmetric, may lead to fusion
• Pseudo-widening of the joint space
– Subchondral bone resorption—blurring
– Erosion sclerosis
– Calcification leading to ankylosis
• Bamboo spine
– Ossification of the anterior spinal ligament and ankylosis of the apophyseal joint
leading to complete fusion
• Syndesmophyte formation—Squaring of lumbar vertebrae’s anterior concavity
– Reactive bone sclerosis
– Squaring and fusion of the vertebral bodies and ossification of the annulus fibrosis at the dorsolumbar and lumbosacral area
• Osteopenia—Bone wash-out
• Straightening of the C-spine
• Hip and shoulder involved to a lesser extent

36. Osteoarthritis
Nonuniform joint space narrowing, subchondral sclerosis and spur formations (osteophytes) are the hallmark of the disease.
Subchondral cysts are often present, while osteoporosis is characteristically absent

37. RADIOGRAPHIC FINDINGS:
• Asymmetric narrowing of the joint space
– Knee—medial joint space narrowing
– Hip—superior lateral joint space narrowing
• Subchondral bony sclerosis—new bone formation (white appearance, eburnation)
• Osteophyte formation
• Osseous cysts—microfractures may cause bony collapse
• Loose bodies
• No osteoporosis/osteopenia (no bone washout)
• Joint involvement
– First CMC
– DIP—Heberden’s
– Large joints—knee and hip
– Luschka joint’s—uncinate process on the superior/lateral aspect of the cervical vertebral bodies (C3-C5) making them concave

40. CT Outstanding bone and soft tissue detail
The next imaging step after plain films for many conditions

41. CT Axial: Cervical
Much more sensitive and specific than plain films for osseous abnormalities

42. CT Sagittal Reformatting
Outstanding detail with no extra scanning
Computer generated from axial scan data

43. MRI
The Gold Standard for cord, thecal sac, nerve roots and disks; very good for ligament and osseous abnormalities, but not as sensitive as CT for some fractures

44. MRI
Outstanding for neural tissue, and for ligaments, tendons, joints, cartilages and muscle
Very sensitive for some bone conditions which are subtle or occult on plain films and CT

45. Degenerative Disease

47. Lumbar spinal stenosis

48. Disc bulge, facet hypertrophy and flaval ligament thickening
Frequently combine to cause central spinal stenosis
Note the trefoil shape of stenotic spinal canal

49. Foraminal stenosis

52. Cantral disk protrusion

53. L5-S1 Disc Extrusion Into Lateral Recess with Impingement of R S1 Nerve Root

54. Schmorl Nodule

55. Spondylolysis / Spondylolisthesis

56. Infectious Spondylitis / Diskitis

57. Pyogenic Spondylitis / Diskitis with Epidural Abscess

58. Spinal TB (Pott’s Disease)
Prominent bone destruction
More indolent onset than pyogenic
Involvement of several VB’s

59. Radiology for the peripheral joints

60. Shoulder -- External Rotation View

62. MRI of the shoulder with its excellent soft tissue discrimination offers the best noninvasive way to study the shoulder. MRI gives us direct imaging of the rotator cuff, muscles and tendons of the glenohumeral joint in multiplanar projections.

63. knee

64. Grading of knee OA radiologic findings
1 = minimal or no changes;
2 = questionable formation of osteophytes or joint-space narrowing;
3 = osteophytosis and joint-space narrowing;
4 = end stage, with bone-to-bone interface;