IMAGING IN SPINAL TRAUMA 13.6.23 FINAL.pptx

IMAGING EVALUATION IN
SPINAL TRAUMA
13.6.23
SYED MAQSOOD

INTRODUCTION
• The spine is composed of 33 vertebrae: 7 cervical, 12 thoracic, 5 lumbar, a sacrum of 5
fused segments, and a coccyx of 4 fused segments.
• Fractures of the spinal column are found most commonly at C1-C2, C5-C7, and T12-L1.
• Results mostly from automobile accidents and sports activities.
• Flexion is the most common line of force in spinal injuries.
• Spinal cord injuries occur in 10-14% of spinal fractures and dislocations.
• Fractures of cervical spine produces neurological damage in approx. 40% of cases.

• Structurally, the first and second cervical vertebrae possess anatomic features
distinct from those of the remaining five cervical vertebrae
• The first cervical vertebra, C1 or Atlas, is anosseous ring consisting of anterior and
posterior arches connected by two lateral masses. The atlas has no body; its main
structures are the lateral masses, also called articular pillars.
• The second vertebra, C2 or Axis, is a more complex structure whose distinguishing
feature is the odontoid process, also known as the dens (tooth), projecting
cephalad from the anterior surface of the body.
ANATOMY

RADIOGRAPHS
3 Standard Views
Lateral view Anteroposterior (AP) view AP odontoid peg view/Open
Mouth veiw

Lateral view. (A) For the erect lateral view of the cervical spine, the patient is standing or
seated, with the head straight in the neutral position. The central beam (red broken line) is
directed horizontally to the center of the C4 vertebra (at the level of the chin). (B) For the cross-
table lateral view, the patient is supine on the radiographic table. The radiographic cassette (a
grid cassette to obtain a clearer image) is adjusted to the side of the neck, and the central beam
is directed horizontally to a point (red dot) approximately 2.5 to 3 cm caudal to the mastoid tip.
LATERAL VIEW

Alignment: 5 contour lines
o Anterior vertebralline
o Posterior vertebral line
o Spinolaminarline
o Posterior spinousline
o Clivusodontoid line, drawn from the
dorsum sellae along the clivus to the
anterior margin of the foramen
magnum should point to the tip of the
odontoid process at the junction of the
anterior and middle thirds.

• Height and density of
vertebral body should
be assessed
• Disc space - should be
uniform
• Assess spaces between
the spinous process

Predental space:
o Distance between the posterior
aspect of anterior arch of Atlas
(C1) and the anterior aspect of
odontoid process.
o Should be <3mm in adults and
<5mm in children.

• The lateral view of the cervical spine, including the lower part of
the skull, is extremely important to evaluate the vertical
subluxation involving the atlantoaxial articulation and the
migration of the odontoid process into the foramen magnum.
• Several measurements are helpful to determine atlantoaxial
impaction or cranial settling resulting in superior migration of
the odontoid process.

The Chamberlain line -This line is
drawn from the posterior margin of
the foramen magnum (opisthion) to
the dorsal (posterior) margin of the
hard palate. The odontoid process
should not project above this line
more than 3 mm; a projection of 6.6
mm (±2 standard deviation [SD]) above
this line strongly indicates cranial
settling.

The McRae line
• This line defines the opening of the
foramen magnum and connects the
anterior margin (basion) with posterior
margin (opisthion) of the foramen
magnum.
• The odontoid process should be just
below this line or the line may intersect
only at the tip of the odontoid process.
• In addition, a perpendicular line drawn
from the apex of the odontoid to this line
should intersect it in its ventral quarter.

The McGregor line
• This line connects the posterosuperior
margin of the hard palate to the most
caudal part of the occipital curve of the
skull.
• The tip of the odontoid normally does not
extend more than 4.5 mm above the line.

SOFT TISSUE
• Nasopharyngeal space (C1) – 7mm
• Retro-pharyngeal space (C2-C4) – 5-
7mm
• Retro-tracheal space (C5-C7) – 22mm
(adults) and 14mm (children)

Anteroposterior view. (A) For the anteroposterior view of the cervical spine, the patient is either erect or
supine. The central beam is directed toward the C4 vertebra (at the point of the Adam's apple) at an angle
of 15 to 20 degrees cephalad. (B) The radiograph in this projection demonstrates the C3-7 vertebral bodies
and the intervertebral disk spaces. The spinous processes are seen superimposed on the bodies,
resembling teardrops. The C1 and C2 vertebrae are not adequately seen.

• A variant of the anteroposterior projection known as the open-mouth view
may also be obtained as part of the standard examination.
• This view provides effective visualization of the structures of the first two
cervical vertebrae.
• The body of C2 is clearly imaged, as are the atlantoaxial joints, the
odontoid process, and the lateral spaces between the odontoid process
and the articular pillars of C1.

Open-mouthview.-For the open-mouthview, the patient is positioned in the same manner as for the
supine anteroposteriorprojection; the head is straight, in the neutral position.With the patient's mouth
open as widely as possible, the central beam is directed perpendicularto the midpoint of the open mouth.
During the exposure, the patient should softly phonate “ah” to affix the tongue to the floor of the mouth so
that its shadow is not projected over C1 and C2

Swimmer's view
• (A) For the swimmer's view of
the cervical spine, the patient is
placed prone on the table with
the left arm abducted 180
degrees and the right arm by the
side, as if swimming the crawl.
• The central beam is directed
horizontally toward the left
axilla. The radiographic cassette
is against the right side of the
neck, as for the standard cross-
table lateral view.
• (B) The radiograph obtained in
this projection provides
adequate visualization of the C7,
T1, and T2 vertebrae, which
would otherwise be obscured by
the shoulders.

CT
• MDCT is the preferred initial imaging modality in blunt spinal trauma
patients.
• Should include from cranio-cervical junction to the level of third thoracic
vertebral body.
• Has been shown to detect almost 100% of fractures.
• Malalignment and soft tissue swelling, in the absence of bony injury
indicates ligament disruption.

MRI
Modality of choice in assessing soft tissue injuries, spinal cord injury, and
intervertebral discs and ligaments.
Whole spine should be imaged in sagittal plane.
Axial sections are targeted at areas of abnormality.
Sagittal sequences – T1 and T2 weighted fat-saturated sequences.
STIR sequence can be used as an alternative.

MECHANISM OF
CERVICAL SPINE
INJURY

• Daffner et al stressed, vertebral fractures occur in predictable and
reproducible patterns that are related to the type of force applied to the
vertebral column.
• The same force applied to the cervical, thoracic, or lumbar spine will result
in injuries that appear quite similar, producing a pattern of recognizable
signs that span the spectrum from mild soft-tissue damage to severe
skeletal and ligamentous disruption
• Daffner termed these patterns fingerprints of spinal injury .
• They depend on the mechanism of injury, which may be an excessive
movement in any direction: flexion, extension, rotation, vertical
compression, shearing, distraction—or a combination of these.

• Flexion: most common
mechanism
• anterior atlantoaxial
subluxation
• anterior
subluxation (hyperflexion
sprain)
• anterior wedge fracture
• clay-shoveler fracture
• flexion teardrop fracture
• bilateral facet dislocation
• hyperflexion fracture-
dislocation
• lateral flexion
• unilateral occipital condyle
fracture
• lateral mass C1 fracture
• flexion-rotation
• unilateral facet dislocation
• rotatory atlantoaxial dislocation
• Extension
• hangmanfracture
• extension teardropfracture
• posterior arch C1 fracture
• posterior atlantoaxial
subluxation
• extension-rotation
• articularpillar fracture
• floatingpillar
• Axial loading/compression
• burst fracture (with axial
loading)
• Jefferson fracture
• Complex injuries
• atlantooccipital
dislocations (shearing)
• occipitalcondyle fracture
• odontoid process fracture

• Of the greatest initial importance in suspected cervical injuries, however,
is the question of stability of a fracture or dislocation.
• Stability of the vertebral column depends on the integrity of the major
skeletal components, the intervertebral disks, the apophyseal joints, and
the ligamentous structures.
• One of the most important factors is the integrity of the ligaments of the
spine: the supraspinous and interspinous ligaments, the posterior
longitudinal ligament, and the ligamenta flava, which together with the
capsule of the apophyseal joints constitute the so-called posterior
ligament complex of Holdsworth .

FLEXION INJURIES
• Hyperflexion sprain
• Wedge compression fracture
• Unilateral interfacetal dislocation
• Bilateral interfacetal dislocation
• Hyperflexion teardrop fracture-
dislocation
• Spinous process fracture

HYPERFLEXION SPRAIN
• Injuries to the soft tissues of the
spine without fracture.
• Radiograph shows angulation of
anterior spinal line with widening of
gap between two spinous
processes.

HYPERFLEXION SPRAIN - MRI
• Edema in the posterior soft tissues
indicating a hyperflexion injury
• Edema in the vertebrae of the lower C-
spine and upper T-spine indicating bone
bruise as a result of axial loading.

WEDGE COMPRESSION FRACTURE
• Anterior wedging of
3mm or more
• Increased concavity
along with increased
density due to bony
impaction
• Usually involves the
upper endplate

UNILATERAL INTERFACETAL
DISLOCATION
• Unilateral interfacet dislocation is due to
a hyperflexion injury with rotation
• Superior facet on one side slides over the
inferior facet and becomes locked
• Anterior subluxation of the upper
vertebral body of about 25% of the AP
diameter of the body

• Malalignment of the spinous
processes - rotatory injury.
• Spinous processes of C4 and C5
seem shorter on the lateral view
AP Lateral

CT confirms the unilateral
dislocation.
The contralateral facet
joint is only distracted.
Inverted hamburger sign

BILATERAL PERCHED FACETS
• This type of vertebralsubluxation occurs as a result of a flexion injury. There is
disruptionof the posteriorligamentous complex, and the inferior and superior
articular processes of the involved vertebrae are in apposition.
• This injury is best diagnosed on the lateral and oblique projections of the cervical spine,
or CT with sagittal and oblique reformation.

Perched facets. A 34-
year-old woman
injured her neck in a
skiing accident. (A)
Pillar view of the
cervical spine
demonstrates
bilateral obliteration of
the facet joints at the
C6-7 level. The joints
above appear normal.
Displacement of the
spinous processes to
the right (arrows) is
the result of rotation.
(B) Lateral radiograph
shows perched facets
of vertebrae C6 and C7
(arrow).

BILATERAL LOCKED FACETS
• Bilateral dislocation of the cervical spine in the facet joints is the result of
extreme flexion of the head and neck; it is an unstable condition caused by
extensive disruption of the posterior ligament complex.
• Interlocking of the articular facets is initiated by the forward movement of the
inferior articular facet of the upper vertebra over the superior articular facet of
the underlying vertebra.
• This causes the lamina and spinous process of the two adjacent vertebrae to
spread apart and the vertebral bodies to sublux.

• In the later stage of dislocation, the inferior articular facet of the upper
vertebra locks in front of the superior articular facet of the lower vertebra,
which results in complete anterior dislocation.
• The configuration of this injury leads to complete disruption of the
posterior ligament complex, the posterior longitudinal ligament, the
annulus fibrosus, and frequently the anterior longitudinal ligament.
• It is also associated with a high incidence of cervical spinal cord damage.

Soft tissue swelling anteriorly
Disruption of the disc
Non-hemorrhagic cord injury

FLEXION TEAR DROP FRACTURE
• Result of a combination
of flexion and compression.
• Teardrop fragment comes from the
anteroinferior aspect of the vertebral body.
• Posterior part of the vertebral body is displaced
backward into the spinal canal.
• Facet joints and interspinous distances are
widened and the disc space may be narrowed.

• Teardrop fracture,, is the most serious and
unstable of cervical spine injuries.
• Disruption of the anterior longitudinal
ligament may cause avulsion of a teardrop-
shaped fragment of the anterior surface of
the body of C5.
• This fracture is also typified by posterior
displacement of the involved vertebra and
fracture of its posterior elements.
• Depending on the severity of the injury,
varying degrees of spinal cord damage
may result.

SPINOUS PROCESS FRACTURE
• Mechanism- Forced flexion action of
the head and upper cervical spine,
opposed action of the interspinous &
supra-spinous ligament
• Oblique avulsion fracture of the
spinous process of the C6, C7 and T1
vertebra (Clay-shoveler fracture)
• Stable fracture

CLAY SHOVELER'S FRACTURE.
• A 33-year-old man injured his neck in wrestling
competition.
• Sagittal CT reformatted image of the cervical spine shows a
displacedfracture of the spinous process of C7 (arrow).

EXTENSION INJURIES
• Posterior arch fracture
• Extension teardrop fracture
• Hangman fracture

POSTERIOR ARCH FRACTURE
• Most common fracture of Atlas
• Posterior arch of atlas compressed
between occiput and large posterior
arch of axis during severe
hyperextension
• Occasionally lead to serious vascular
injury

EXTENSION TEARDROP
FRACTURE
• Occurs when the anterior longitudinal
ligament pulls a bony fragment from the
inferior aspect of the vertebra
• True avulsion
• Associated with the central cord syndrome
due to buckling of the ligamentum flava into
spinal canal

HANGMAN FRACTURE
• Traumatic spondylolisthesis of axis(C2)
• Bilateral fracture of pars interarticularis or
isthmus
• Most frequent fracture in fatal traffic accidents.
• Neurological involvement is rare

CLASSIFICATION OF HANGMAN’S FRACTURE
Type I (65%)
 Hairline fracture
 C2-C3 disc normal
Type II (28%)
 Displaced C2
 Disrupted C2-C3 disc
 Ligamentous rupture with instability
Type III (7%)
 Displaced C2
 C2-C3 bilateral interfacet dislocation
 Severe instability

AXIAL LOADING - BURST FRACTURE
• High energy axial loading
• Loss of vertebral height, more on
anterior portion
• Retropulsion of posterior
vertebral body into spinal canal
• Interpedicular widening

JEFFERSON FRACTURE
• Burst fracture of C1
• Splitting of the C1 ring with fracture of both anterior and posterior arch
• Unilateral or bilateral
• Radiograph : Spreading apart of lateral masses creating paraodontoid
spaces.
• Total offset >8mm signifies rupture of transverse ligament

ODONTOID PROCESS FRACTURE
11-13% of cervical spine injuries.
75% of cases are children.
Anderson and D’Alonzo classification ( I,II,III)
Associations:
 Atlanto-axial dislocations
 Jefferson fracture
Radiographic features may be subtle
Should be differentiated from Os odontoideum

ANDERSON AND D’ALONZO CLASSIFICATION
Avulsion of the tip of
the dens
Type I Type II Type III
Through the base of the dens
Most common fracture
Unstable and poor healing
Through the body of the axis
and sometimes facets
Better prognosisthan type II

SLIC SCORE
(SUBAXIAL CERVICAL SPINE INJURY CLASSIFICATION)
Severity score for cervical spine trauma that helps in determining
treatment and prognosis
SLIC is based on the assessment of three independent predictors of
clinical outcome:
 Morphology of Injury
 Disco-ligamentous Integrity
 Neurologic Status

The score of each
domain is added to give
the total SLIC score,
which helps determine
whether surgery is
indicated
≤3: non-surgical
management
= 4: equivocal
≥ 5: surgical
management

RADIOGRAPHS
2 views
o Anteroposterior view
o Lateral view
Alignment should be assessed
Spinous process should be central with
symmetrical appearance of pedicles and
vertebral body

• For the anteroposterior view of the
thoracic spine, the patient is supine
on the table, with the knees flexed
to correct the normal thoracic
kyphosis.
• The central beam is directed
vertically about 3 cm above the
xiphoid process.
• On the radiograph in this
projection, the vertebral end plates
and pedicles and the intervertebral
disc spaces are seen.
• The height of the vertebrae can be
determined, and changes in the
paraspinal line can be evaluated.

(A)For the anteroposterior projection of the lumbar spine, the patient is supine on the table, with the knees flexed to
eliminate the normal physiologic lumbar lordosis. The central beam is directedvertically to the center of the abdomen at
the level of the iliac crests.
(B) The radiograph in this projection demonstrates the vertebral bodies, the vertebral end plates, and the transverse
processes; the intervertebral disk spaces are also well delineated. The spinous processes are seenen face, appearing
as teardrops; the pedicles, also visualized en face, project as oval densities on either side of the bodies.

Anteroposterior coned-down view of the lumbar spine demonstrates a
characteristic configuration of the lower aspects of L3 and L4. This
“Cupid's bow” contour is lost in cases of compression fracture.

• For the lateral view of the thoracic spine, the
patient is erect with the arms elevated.
• To eliminate structures that would obscure the
bony elements of the thoracic spine, the patient is
instructed to breathe shallowly during the
exposure.
• The central beam is directed horizontally to the
level of the T6 vertebra with about 10-degree
cephalad angulation.
• The radiograph in this projection demonstrates a
lateral image of the vertebral bodies and
intervertebral disk spaces.

For the lateral projection of the lumbar spine, the patient is recumbent on the radiographic table
on either the left or right side; the knees and hips are flexed to eliminate the lordotic curve. The
central beam is directed vertically to the center of the body of L3, at the level of the patient's waist.
(B) The lateral radiograph of the lumbar spine allows adequate evaluation of the vertebral bodies,
pedicles, and spinous processes as well as the intervertebral foramina and disk spaces.

• Oblique view of the lumbar spine. (A) For the posteroanterior oblique projection of the lumbar spine, the patient is
recumbent on the table, with the right side rotated 45 degrees to demonstrate the rightsided articular facets.
(Elevation of the left side allows demonstration of the left-sided articular facets.) The central beam is directed
vertically toward the center of L3.
• (B) The posteroanterior oblique radiograph demonstrates the facet joints, the superior and inferior articular process,
the pedicles, and the pars interarticularis.

• Thoraco-lumbar spine CT Should be performed as part of polytrauma
CT protocol, with IV contrast for assessment of vascular injury
• CT is very useful in diagnosing / excluding thoracic spine injury
• Thoracolumbar junction, more prone for pure ligamentous injury
without bony fractures
• MRI – gold standard for assessing purely ligamentous injury

DENIS THREE-COLUMN CONCEPT
Any injury that involves two of three columns unstable

TLICS
(THORACO-LUMBAR INJURY CLASSIFICATION AND
SEVERITY SCORE)

FLEXION COMPRESSION INJURY
• Wedge compression fracture with
mild kyphosis
• Horizontal sclerotic band of
trabecular impaction
• Frequently involves superior
endplate
• Posterior cortex of body intact
(distinguishes from burst fracture)

BURST FRACTURE
• Axial compressive force through the spine
• Retropulsion of posterosuperior vertebral body
fragment
• Widening of interpedicular distance
• Posterior bowing of the vertebral body margin is
diagnostic of an axial compression (burst) fracture.

• Burst fracture gets 2 points for morphology in the TLICS
• In the absence of a neurologic deficit, PLC integrity should be confirmed at
MR imaging, if conservative management is planned

FLEXION DISTRACTION INJURY
• Rupture of posterior bony and/or ligamentous
structures by distraction, with variable degree
of compression of anterior column
• Common at thoracolumbar junction
• High chance of cord injury
• classically caused by a deceleration-type
motor vehicle accident

Fracture-dislocation. Lateral radiograph of the thoracolumbar spine (A) and sagittal
reformatted CT image (B) demonstrate characteristic features of a flexion-distraction
type of fracture-dislocation.

TRANSLATION/ROTATION INJURY
• Includes all fractures that are result of
displacement in horizontal plane
• Often unilateral or bilateral facet dislocation is
seen
• Severe type of injury, always involves the PLC
• In TLICS 3 points for the morphology ,3 points for
the PLC, total of 6 points indicating the need for
surgical stabilization.

Chance fracture:
• Pure osseous
• Fracture occur through one vertebra, passing
through pedicles and spinous process at single
level
• Involvement of posterior ligamentous
structures without posterior bony injury – soft-
tissue Chance injury
• High association with intra-abdominal injuries

Bony Chance Soft tissue Chance

THE SPECTRUM OF SEAT-BELT INJURIES
INVOLVING THE LUMBAR SPINE.

(C) Sagittal CT reformation demonstrates the fracture of posterior elements to
better advantage. (D) Parasagittal MR image demonstrates disruption of the
posterior ligaments and a large soft-tissue hematoma. The findings are typical of a
two-level seat-belt injury.

SPONDYLOLYSIS AND SPONDYLOLISTHESIS
• Spondylolysis, a defect in the pars interarticularis (the junction of the
pedicle, articular facets, and lamina) of a vertebra (neck of the “Scotty dog”),
may be an acquired abnormality, secondary to an acute fracture, or, as is
more commonly the case, it may result from chronic stress (stress
fracture).
• Spondylolisthesis denotes the slippage of one vertebra relative to the one
below.
• It is encountered more commonly in the lower lumbar spine and has a high
prevalence among athletes.
• These abnormalities are seen predominantly in the lumbar spine (90% of
cases) and most commonly at the L4-5 and L5-S1 levels.

Types of spondylolisthesis. Spondylolisthesis may occur in association with
spondylolysis resulting from a defect in the pars interarticularis, or secondary to
degenerative disk disease and degeneration and subluxation of the apophyseal joints
(pseudospondylolisthesis).

The spinous-process sign - The spinous-process sign can help differentiate true
spondylolisthesisfrom pseudospondylolisthesis by the appearance of a step-offin the
spinous processes above the level of vertebral slip in the former and below that level
in the latter (red arrows indicate direction of slip).

CT of spondylolysis. (A) Axial and (B) sagittal reformatted CT
images show bilateral defect in the pars interarticularis of L5
vertebra (arrow).

• A severe degree of spondylolisthesis at the L5-S1 level can be identified on
the anteroposterior radiograph by the ventrocaudal displacement of L5
over the sacrum.
• This configuration creates curvilinear densities called as inverted
Napoleon's hat sign .

Inverted Napoleon's hat sign. (A) Anteroposterior radiograph of the lumbosacral spine
in a 21year-old man with severe (grade 4) spondylolisthesis shows curvilinear densities
in the sacral area forming an inverted Napoleon's hat.

THE SIMPLE GRADING OF SPONDYLOLISTHESIS PROPOSED
BY MYERDING IS BASED ON THE AMOUNT OF FORWARD
SLIPPING.

TRAUMATIC SACRAL INJURIES
Isolated sacral fractures are uncommon
2 types:
Horizontal
o Most common type
o Common at S3-S4 level
o High horizontalfractures occur from high
falls (suicidaljumper’s fracture)
Vertical
o Usually indirect trauma to pelvis
o Visible in frontal radiograph
o Usually runs nearly the entire length of
sacrum

TRAUMATIC COCCYDYNIA
Coccydynia has a myriad of causes but is most commonly found in the
posttraumatic setting.
Patients often have a history of recent or remote trauma to the region
and develop chronic mechanical symptoms

Figure 15. Patient positioning and setup for seated lateral radiography of the coccyx. Illustration shows the patient in a seated position on a hard-surface stool with their
thighs horizontal, which may require placing their feet on a footrest, depending on the height of the stool. They are then instructed to lean back to the point of maximum
tenderness and hold in this position for image acquisition. The arm position may vary depending on patient comfort and how far they recline.

Figure 9a. Coccyx fracture in a 72-year-old man with coccygeal pain after falling off a chair. (a) Lateral radiograph shows a fracture (arrows) of the first coccygeal body. (b)
Sagittal T1-weighted image demonstrates T1-hypointense and short inversion time inversion-recovery (STIR)–hyperintense (not shown) edematous signal intensity
(arrowhead) corresponding to the suspected site of fracture, as well as cortical offset posteriorly, confirming the diagnosis. US-guided pericoccygeal injection was
successfully performed for pain management.

Figure 9b. Coccyx fracture in a 72-year-old man with coccygeal pain after falling off a chair. (a) Lateral radiograph shows a fracture (arrows) of the first coccygeal body. (b)
Sagittal T1-weighted image demonstrates T1-hypointense and short inversion time inversion-recovery (STIR)–hyperintense (not shown) edematous signal intensity
(arrowhead) corresponding to the suspected site of fracture, as well as cortical offset posteriorly, confirming the diagnosis. US-guided pericoccygeal injection was
successfully performed for pain management.

INJURY TO THE DISCOVERTEBRAL
JUNCTION
• One of the most frequent conditions affecting the discovertebral junction is
herniation of an intervertebral disk.
• Injury to the intervertebral disk and the diskovertebral junction can result
from acute trauma or from subtle subclinical, often endogenous injury.
• Depending on the direction of herniation of disk material, a spectrum of
injuries of the intervertebral disk and adjacent vertebrae may be seen .

INTRAVERTEBRAL DISC HERNIATION
• Ventrocaudal disc herniation, as well as ventrocephalad herniation, which is
much less commonly seen, produces an abnormality known as limbus
vertebra.
• Herniation of disc material into a vertebral body at the site of attachment of the
annulus fibrosusto the body's rim separates a small, triangular fragment of
bone, which is commonly mistaken for an acute fracture or infectious
spondylitis.
• Reactive bone sclerosis adjacent to the defect, however, indicates a chronic
process. The adjacent disc space is invariably narrowed, and a radiolucent cleft
known as the vacuum phenomenon may be seen in the disc space, representing
degeneration of the disk .This abnormality, which is invariably asymptomatic, is
the product of chronic, endogenoustrauma.

LIMBUS VERTEBRA
• Lateral radiographof the lumbar spine in a 55-year-old
woman with breast cancer who underwent radiographic
examinationto exclude bone metastases shows anterior
intravertebraldisk herniationinto the body of L2 (limbus
vertebra).
• Note the vacuum phenomenon(arrow), indicating disk
degeneration.

Secondary ossification centers
• The secondary ossification centers of the
vertebral ring apophysis in the growing
skeleton, as seen here in a 5-year-old girl,
should not be mistaken for limbus vertebrae.

ANNULAR TEARS
• Tears or fissures of the annulus fibrosus of lumbar intervertebral discs
may occur secondary to trauma and may also be caused by degenerative
changes of the disc related to normal aging.
• These tears represent separations between annular fibers, separations of
annular fibers from their vertebral insertions, or breaks through these
fibers in any orientation, involving one or more layers of the annular
lamellae.
• Annular tears are found in both symptomatic and asymptomatic
individuals.

IMAGING IN SPINAL TRAUMA 13.6.23 FINAL.pptx

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