10173-08_ON2506-Tilson.

qxd

11/9/06

3:54 PM

Page 415

An Overview of Radiography, Computed Tomography, and Magnetic Resonance Imaging in the Diagnosis of Lumbar Spine Pathology
Elwin R. Tilson Gloria Deal Strickland Sharyn D. Gibson

When patients present with symptoms associated with lumbar spine pathology, often a series of diagnostic examinations of escalating sophistication are utilized. To obtain a diagnosis, the initial study is usually done on lumbar spine radiographs, which demonstrate gross bony pathologies, spinal alignment, and bone density. Frequently, additional high-cost invasive or noninvasive procedures may be required. Myelography is used to examine the spinal cord, nerve root bundles, and possible intrusion of the vertebral disk into the spinal canal. Computed tomography is most useful for imaging small bony structures and, when coupled with myelography, can demonstrate soft tissue abnormalities in the spinal canal. Magnetic resonance imaging is, however, the preferred modality for imaging soft tissue.

umbar spine plain x-ray films (radiographs) are considered for a general survey radiographic examination to evaluate disease processes and fractures. Patient symptoms include persistent low back pain, a history of trauma, loss of feeling or tingling in the legs, weakness, and/or painful ambulation. Routine radiography is less expensive than computed tomography (CT) or magnetic resonance imaging (MRI) procedures and is usually the first procedure in the diagnostic process for lumbar spine pathology. Lumbar spine radiographs are fast, noninvasive, and usually pain-free. If the patient has discomfort in the recumbent position, the patient may be examined in the erect position (Ballinger & Frank, 2003). Radiographs are two-dimensional (2D) images of threedimensional (3D) structures, which result in superimposition of anatomical structures. Consequently, it is usually necessary to obtain multiple images taken at different angles. A term used in radiography to describe the path of the radiation or x-ray beam is projection. Typically, the spine examination consists of an anterior-to-posterior (AP) projection, a lateral projection, two oblique projections, and occasionally a detailed image of the L5-S1 disk space (Ballinger & Frank, 2003).

Optimally, it is beneficial to have the patient empty the bladder and bowels prior to the examination. Overlying gas and fecal material may compromise radiographic clarity. A urine-filled bladder may cast a shadow on the sacrum and the distal end of the vertebral column (Ballinger & Frank, 2003). Multiple structures are well demonstrated on the AP lumbar spine image. Structures labeled in Figure 1 are the vertebral body (A), the spinous process (B), intervertebral disk space (C), examples of colonic gas (D), examples of fecal material (E), and the left 12th rib (F). The zygapophyseal or facet joint is not demonstrated in the AP projection of the lumbar spine, but is seen in the oblique position. The articulation of the superior and inferior articular processes form the zygapophyseal joint. In Figure 2, the rectangle indicates the L2 vertebral body, A is the superior articular process of L3, B is the inferior articular process of L2, C is the superior articular process of L4, D is the inferior articular process of L3, and E and F are the pedicles of L3 and L4, respectively. A lateral lumbar radiographic image is seen in Figures 3 and 4. Compression fractures of the vertebral body, bone density, and spinous processes are typically well seen on this radiographic view. In Figure 3, A indicates one zygapophyseal joint, B points to pedicle screw placement, C depicts the L4 spinous process, and D the L3/L4 intervertebral disk space. The squares in both Figures 3 and 4 indicate the vertebral body of L1. Note the loss of bone density (osteoporosis) in the vertebral body in Figure 4 as indicated by grayness of the body and the lack of differentiation from the surrounding abdominal soft tissue. Compare this with the L1 vertebra in Figure 3, which is of normal bone density.
Elwin R. Tilson, EdD, RT(R)(QM)(M)(CT), FAERS, Professor of Radiologic Sciences, Armstrong Atlantic State University, Savannah, GA. Gloria Deal Strickland, EdD, RT(R)(QM)(M), Associate Professor of Radiologic Sciences, Armstrong Atlantic State University, Savannah, GA. Sharyn D. Gibson, EdD, RT(R), Professor and Department Head of Radiologic Sciences, Armstrong Atlantic State University, Savannah, GA.
November/December 2006 Volume 25 Number 6

Orthopaedic Nursing

415

10173-08_ON2506-Tilson.qxd

11/9/06

3:54 PM

Page 416

FIGURE 1. Annotated AP lumbar spine radiograph. (A) Vertebral

body, (B) spinous process, (C) intervertebral space, (D) example of colonic gas, (E) example of fecal material, and (F) left 12th rib.

FIGURE 2. Right posterior oblique radiograph of the lumbar spine. The body of L2 is outlined by the rectangle. (A) Superior articular process of L3, (B) inferior articular process of L2, (C) superior articular process of L4, (D) inferior articular process of L3, and (E) pedicles of L3 and L4.

One of the limitations of a routine lumbar radiographic examination is that certain structures and pathologies are not visible. For example, the spinal cord, the intervertebral disks, nerve roots, and many soft tissue injuries are not visible on plain radiographs. When these structures need to be assessed, other examinations such as myelography, CT, and MRI are helpful.

Myelography
One cause of low back pain may be associated with neurological impairment due to pressure on the spinal cord (Magee, 1997). This pressure may be associated with degenerative changes in the bony structure of the vertebra, traumatic fracture fragments, or intervertebral disk herniation. Myelography may show the relationship of bony to neural elements (Eisenberg & Johnson, 2003). This procedure involves lumbar puncture in which a small amount of cerebral spinal fluid is removed and replaced by an iodine416
Orthopaedic Nursing November/December 2006 Volume 25

based, water-soluble contrast media. Contrast media outlines the spinal cord, the nerve root bundles, and the edges of the intervertebral disks. Images are taken using both fluoroscopy and radiography and can be coupled to a CT examination as indicated below. Figure 5 is a positive image in which bone is dark gray and soft tissue is white. The contrast media is the dark column overlying the vertebral bodies and filling the spinal column. The two black arrows indicate stranding around the nerve root bundles. Figure 6 is a traditional negative image of the same examination. In this image, bone and contrast media appear white. The white arrows on this image indicate nerve root bundles. The white column overlying the vertebral bodies is the contrast mediafilled spinal canal. In a myelogram study, two of the areas that are evaluated are the intervertebral spaces and potential intrusion
Number 6

10173-08_ON2506-Tilson.qxd

11/9/06

3:54 PM

Page 417

FIGURE 3. Lateral lumbar spine radiograph. The body of L1 is

outlined by the rectangle. (A) Zygapophyseal joint, (B) screw placement, (C) spinous process, and (D) intervertebral joint space.

FIGURE 4. Lateral lumbar spine radiograph demonstrating osteoporosis as indicated by the loss of bone density (compared to the surrounding soft tissue) in the L1 vertebral body outlined by the rectangle.

of the disk into the spinal canal. In Figure 7, a lateral myelogram image, the black arrows indicate the intervertebral space and the white arrows indicate the intersection of the disk and the spinal canal. Note the Ushaped bulge pushing into the spinal canal at the point of the intersection. This is typical of intervertebral disk intrusion into the spinal canal.

Computed Tomography
Computed tomography is a technology using x-ray radiation and an array of radiation detectors that surround the part being examined. On the basis of the amount of radiation absorbed by different body parts from multiple angles, it is possible to reconstruct a 2D or 3D image of the anatomy. In the 2D reconstruction, the computer produces slices through the part of interest. In the 3D reconstructions, the computer produces an image that can be rotated and viewed from any angle either as a solid or semitransparent structure. Computed tomography has good contrast resolution, which means objects of slightly different physiological densities are easily distinguishable. Although

CT is often used to examine soft tissue in the chest and abdomen, it is not as useful for examining the soft tissues associated with the lumbar spine. Computed tomography, however, is extremely useful in examining the spinal bony structures such as degenerative facet changes and pathology associated with trauma. These pathologies are especially important as they may or may not infringe upon the spinal canal (Seeram, 2000). A representative example of a 2D CT slice of a lumbar vertebra is shown in Figure 8. This is a cross-sectional slice through the vertebra, where A is the body of the vertebra, B is the spinal canal, C is the transverse processes, D is the spinous process, E is the pedicle, and F is the lamina. When combined with a myelogram, the CT scan demonstrates important information about soft tissue structures such as the spinal cord nerve roots. The white arrows in Figure 9 indicate the spinal cord with contrast media highlighting the soft tissue in the spinal canal. Note the multiple dark nerve root bundles inside the spinal cord. Compare
November/December 2006 Volume 25 Number 6

Orthopaedic Nursing

417

10173-08_ON2506-Tilson.qxd

11/9/06

3:55 PM

Page 418

FIGURE 5. Positive image of a lumbar myelogram with arrows

indicating nerve root bundles.

FIGURE 7. Lateral projection of lumbar myelogram with dark arrows indicating intervertebral disk space and white arrows indicating intervertebral disk bulging into spinal cord.

FIGURE 6. Negative image of a lumbar myelogram with arrows

indicating nerve root bundles.

FIGURE 8. Axial CT image of lumbar vertebra using bone window settings. (A) Body of the vertebra, (B) spinal canal, (C) transverse process, (D) spinous process, (E) pedicle, and (F) lamina.
Number 6

418

Orthopaedic Nursing

November/December 2006

Volume 25

10173-08_ON2506-Tilson.qxd

11/9/06

3:55 PM

Page 419

the image looks similar to the traditional lateral lumbar radiograph in Figure 3. The white box in Figure 10 surrounds a fractured vertebra as demonstrated by the lack of a smooth superior surface and the fracture line from the superior aspect to the inferior aspect of the body.

Magnetic Resonance Imaging

Unlike CT, MRI is very useful in demonstrating soft tissues without the addition of the contrast media and therefore is not an invasive procedure. Magnetic resonance imaging requires a strong external magnetic field, a source of radio waves, a radio wave receiver, and an abundance of mobile hydrogen protons. Hydrogen is abundant in human tissue making up approximately two thirds of atoms within the body (Woodward & Freimarck, 1995). When the patient is placed in a strong external magnetic field, the hydrogen protons align with the magnetic field. Because there is only one proton in the hydrogen nucleus, it spins like a spinning top (Westbrook & Kaut, 1998). Envision the proton as spinning like a top that begins to lose energy. Owing to the loss of energy, the top starts to wobble and begins moving outwardly from the center. This wobble or precession in atoms occurs at a particular frequency and can be measured and used to create cross-sectional images in any plane. Images are created due to the pulsing of radio frequency waves that manipulate and move the magnetic fields associated with the spinning hydrogen protons. When the radio frequency pulse is terminated, the protons magnetic field

FIGURE 9. Axial CT image of lumbar vertebra and spinal cord (arrows) during CT-augmented myelogram.

this contrast image with area B in Figure 8 where the spinal cord is not depicted. Another use of CT examination of the lumbar spine is that 2D slices can be produced in axial, sagittal, or coronal orientations. Traditional CT slices are in the axial orientation. Standard image reconstructions performed with a lumbar spine CT examination are in the sagittal orientation. Figure 10 is a sagittal CT reconstruction. Note that

FIGURE 10. Sagittal CT reconstruction image of lumbar vertebra demonstrating a fracture of the vertebral body as indicated by the rectangle.

FIGURE 11. Sagittal MRI image of the lumbar spine region demonstrating normal anatomy. (A) Intervertebral disk, (B) cauda equina, (C) spinal cord, and (D) cerebral spinal fluid.
November/December 2006 Volume 25 Number 6

Orthopaedic Nursing

419

10173-08_ON2506-Tilson.qxd

11/9/06

3:55 PM

Page 420

will return to its original position. In doing so, the protons give off excess energy in the form of radio waves. The radio waves from individual atoms are analyzed by a computer to form images (Woodward & Freimarck, 1995). The MRI parameters known as T1 and T2 represent different methods of tissue relaxation of the hydrogen protons, following manipulation of their magnetic fields (Westbrook & Kaut, 1998). Tissues within the human body consist of various chemical structures containing differing amounts of hydrogen. Because these tissues are chemically different, they relax or return to their original states at different rates. These differing relaxation rates are referred to as T1 and T2 relaxations. T1-weighted images are frequently used for the visualization of anatomy, and T2weighted images are usually the best for visualization of pathology. Magnetic resonance imaging demonstrates spinal alignment, disk height and hydration, vertebral body configuration, intervertebral disk abnormalities, spinal canal size, nerves, and postsurgical changes. Figure 11 is a sagittal MRI image showing normal anatomy. A common abnormality demonstrated by MRI in the lumbar spine region is herniated intervertebral disk (dark bulges as indicated by white arrows in Figure 12). A fracture of an osteopenic L3 vertebral body with the displacement of bone into the spinal canal is shown in Figure 13. The white arrow indicates the canal impingement and the black arrows point to the fracture line of the body.

FIGURE 13. Sagittal MRI image showing a fracture of the vertebral body with displacement of the fracture (black arrows) and infringement of the spinal cord (white arrow).

When a patient presents with possible lumbar spine pathology, there are a wide range of radiologic examinations that may be used for diagnosis. These examinations can be used individually or in combination to provide the clinician with comprehensive imaging data for diagnosis of subtle lumbar spine pathologies.

REFERENCES
Ballinger, P., & Frank, E. (2003). Merrills atlas of radiographic positions and radiologic procedures (Vol. 1, 10th ed.). St. Louis, MO: Mosby. Eisenberg, R., & Johnson, N. (2003). Comprehensive radiographic pathology (3rd ed.). St. Louis, MO: Mosby. Magee, D. J. (1997). Orthopedic physical assessment (2nd ed.). Philadelphia: W. B. Saunders. Seeram, E. (2000). Computed tomography: Physical principles, clinical applications, and quality control. Philadelphia: Saunders. Westbrook, C., & Kaut, C. (1998). MRI in practice. Malden, MA: Blackwell Science. Woodward, P., & Freimarck, R. (1995). MRI for technologists. New York: McGraw-Hill.
Number 6

FIGURE 12. Sagittal MRI image demonstrates a herniated disk at two levels as indicated by the bulging (white arrows) into the spinal canal.

420

Orthopaedic Nursing

November/December 2006

Volume 25