Introduction to Radiographical Anatomy of the Spine p

Department of Radiology, p gy Vancouver General Hospital

Dr. Dr Savvas Nicolaou Director of ER/Trauma Radiology savvas.nicolaou@vch.ca @

Objectives Recognize basic differences between cervical, thoracic and lumbar vertebra cervical vertebra. Be able to identify on a normal spinal radiograph: Vertebral body with correct name (e.g. CIII, LV) Anterior and posterior arch of CI Lateral masses of CI Dens Pedicle Transverse Processes Spinous Processes Superior/inferior articular processes (zygapophysial joint) Pars articularis (lamina between superior and inferior articular processes) Vertebral foramen

Objectives Be bl to identify B able t id tif on CT and MR d MR:

Spinal cord Nerve roots Conus medullaris Subarachnoid space A Annulus fib i l fibrosis Nucleus pulposis

Anatomy Review

Cervical/Thoracic/Lumbar Vertebra

Not all the same. Each have characteristics that differentiate from other vertebrae.

Cervical vertebrae
Typical cervical vertebra:
Smallest in size relative to thoracic and lumbar Presence of foramen transversarium Sh t bifid spinous process Short i Heart shaped vertebral foramen

Atlas (CI) & Axis (CII)

Non-typical vertebrae
- Specialized to facilitate movement of head

Atlas is ring shaped with no vertebral body, two lateral masses

Axis has superior projection from vertebral body dens (also called odontoid)

Thoracic Vertebrae
Articulate with ribs Circular vertebral foramen (vs. heart shaped in cervical) Larger than cervical but smaller than lumbar in size

Lumbar Vertebrae
Large in size Triangular vertebral foramen (vs. heart shaped in cervical and round in thoracic) Thin, long transverse processes , g p

Vertebral Discs
Two layers:
Outer annulus fibrosus
Firm Collagen and fibrocartilage

Central nucleus pulposus

Gelatinous material Helps absorb compression forces The two layers are best visualized using MRI g

Radiograph Views of the Spine

Anterior-Posterior (AP)

Lateral

Lateral View of Cervical Spine

Anterior arch of CI Dens

Posterior arch of CI Pedicle (best seen on oblique image)

CII Vertebral Body

Inferior Articular Process

CIII
CIII-IV Vertebral Disc

Superior Articular Process

CIV

Transverse Process Spinous Processes

CVI
Intervertebral Foramen
(best seen on oblique image)

CVII TI

Vertebral Bodies
Anterior Arch CI

Dens

CIII CIV

CIII CIV

CV CVI CVII

CV CVI CVII TI

Inferior articular process

Zygapophysial joint

Superior articular process

Superior and inferior articular processes = zygapophysial joint

Intervertebral Disc Space

Cervical Spinous Processes

Posterior Arch CI

Transverse Processes

Fractured CVII spinous process (Clay shovellers fracture)

What is the gross abnormality?

(hint: not the metal object)

Normal

AP View
From the AP view, thoracic and lumbar vertebrae create an owl appearance:

Eyes are pedicles Beak is spinous process Face is vertebral body Ears are transverse processes

CVII Vertebral Body

Right Pedicles of CVII & TI

Spinous Processes

Trachea can be shifted in lung pathologies

Spinous Processes

Pedicles

Right Intervertebral g Foramen (CIII nerve)

Pedicle

CIV Vertebral Body

Spinous Processes

Inferior Articular Process

Superior Articular Process

Oblique

Radiographical Views: X-ray

For analysis of CI, CII and dens fractures

Odontoid

Radiographical Views: X-ray

Odontoid

Dens and body of CII centre y Lateral masses of CI right and left

Example of anatomy not where it belongs

Can you see the difference?

Example of anatomy not where it belongs

Lateral masses overhang the CII articular process Jefferson fracture (CI)

Normal

CT Images: Axial

Axial image of vertebra can you tell which level (cervical, thoracic, lumbar) this comes from?

CT Images: Axial

Cervical Vertebra
Foramen transversarium

Heart shaped vertebral f foramen

Short, bifid spinous process

How can you tell? (3 ways)

CT Images: Axial
Cervical Vertebra
Transverse Process Pedicle

Vertebral Body Transverse Process

Pedicle P di l

Lamina

Other important anatomy

CT images: Axial

This vertebra does not look normal, can you identify this ATYPICAL vertebra?

CT Images

Anterior arch

Dens Anterior arch Dens

Foramen transversarium

Right lateral mass

Left lateral mass

Right lateral mass Posterior arch

Left lateral mass

Posterior arch

This is CI (Atlas)

CT Images: Coronal

CT Images - Coronal

Dens

CI lateral mass

CII vertebral body

CI lateral mass

Inferior articular facet CI

Superior articular facet CII CII vertebral body

Intervertebral disc

Can someone identify this vertebra

CV

CT - Sagittal

Reconstructed through R t t d th h vertebral body

Anterior arch CI

Dens CII vertebral t b l body

Spinal p canal

Spinous Processes

Intervertebral disc space

CT - Sagittal

Vertebral bodies with dens and anterior arch of CI

Which body is the arrow pointing to? CV

CT - Sagittal

Spinal canal difficult to differentiate cord from surrounding fluid on CT

CT Images - Sagittal

Inferior articular process p Pars interarticularis Superior articular process

The area between the superior and inferior articular facets is p termed the `pars interarticularis` and is a common site for fractures

The joint formed by these two is called the zygapophysial joint`

Inferior articular p process

Zygapophysial joint is in between the Inferior and Superior Articular processes

Superior articular process

MRI cervical images axial

Intervertebral Foramen

Spinal Cord Lamina

CSF surrounding cord

T2 weighted image

MRI at level of CVI (poorer ( quality than previous)

Patient feels g generalized p pain in left arm

Herniation of the disc, causing impingement of exiting nerve i i t f iti root

MRI sagittal
T2 weighted image g g

Spinous p Process Spinal Cord (dark on MR) CSF surrounding the cord (light on MR) ( g ) Vertebral Body

Intervertebral Disc (cannot differentiate annulus from nucleus due to age related desiccation of disc)

X-ray Thorax AP

Numbering vertebra is easiest from top or bottom (most superior or inferior vertebra articulating with a rib)

Transverse T Process p Spinous Process

Note: The owl appearance is consistent between thoracic and lumbar vertebrae

Pedicle T12 12th rib

Thoracic Lateral

? Vertebral Bodies Intervertebral disc spaces

Intervertebral foramen Inferior Articular Process Superior Articular Process

CT Axial

Two characteristics of thoracic vertebra demonstrated in this axial image 1) Articulation with ribs 2) Round vertebral foramen

CT Sagittal

Vertebral bodies

Intervertebral foramen Inferior articular process Superior articular process

Intervertebral disc spaces Pedicles

Pars interarticularis

X-ray Lumbar AP

12th rib Pedicles Spinous Processes Intervertebral disc space Transverse Processes

Sacrum

TXII

LI

LII

LIII

Transverse processes

L4 and L5 Transverse processes

Spinous processes

Pedicles

TXII LI LII LII LIII LIII LIV Vertebral Bodies

LI

LV

X-ray Lumbar Lateral

LI LII Intervertebral I t t b l Foramen Inferior articular process Superior articular process Pars interarticularis

LIII Intervertebral disc space

LIV

Which nerve exits the intervertebral foramen shown? L2 nerve root

LV

LI LI LII LII Intervertebral Foramen Inferior articular process Superior articular process Pars interarticularis Intervertebral disc I t t b l di space LIII

LIII

LIV

LIV

LV

LV

CT axial - Lumbar

Vertebral body Pedicle Long, thin transverse processes Spinous process Superior articular process Inferior articular process Triangular vertebral foramen

CT axial - Lumbar

Triangular vertebral g foramen Vertebral body Pedicle Long, thin transverse t processes Superior p articular process Inferior articular process

Triangular vertebral foramen f

Spinous process

Spinous process

CT axial - Lumbar

Axial view of this lumbar vertebra shows a joint

Who is the hotshot that can identify the name of this joint?

Are you sure which one is y superior and which is inferior articular process without looking at the previous page?

Zygapophysial Joint

CT axial - Lumbar

Nerve roots are visible on CT and MRI

Nerve roots ( i l d i purple) N t (circled in l ) traversing the intervertebral foramen

CT axial - Lumbar

Can you see the nerve root?

CT axial Top of sacrum

More nerve roots yp y typical Mickey Mouse appearance

CT axial Lumbar post myelogram (contrast in spinal cord)

Nerve roots are easily seen postmyelogram

Nerve roots (black dots) (bl k d t )

CT coronal Lumbar post myelogram

Vertebral body

Intervertebral disc

Transverse process

Nerve roots from cauda equina

CT sagittal Lumbar post myelogram

More nerve roots

MRI axial - Lumbar

Intervertebral disc

Annulus fibrosus Nucleus pulposus Exiting nerve root Intervertebral foramen Nerve roots from cauda equina

MRI coronal - lumbar

Intervertebral I t t b l disc

Annulus fibrosus Nucleus pulposus

MRI sagittal Lumbar

Conus medullaris C d ll i (end of the spinal cord)

End of subarachnoid space

Exiting nerve roots from the top of intervertebral foramen