压缩性骨折的影像学表现

Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Compression FracturesCompression Fractures Eleanor AdamsEleanor Adams Harvard Medical School Year IVHarvard Medical School Year IV Gillian Lieberman, MD Gillian Lieberman, MD September 2006September 2006 22 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD OverviewOverview •• Spine AnatomySpine Anatomy •• ThoracolumbarThoracolumbar FracturesFractures •• CasesCases •• Compression Fractures, Compression Fractures, DdxDdx •• Radiologic Tests of ChoiceRadiologic Tests of Choice •• Treatment OptionsTreatment Options CedarsCedars--Sinai Medical Center, www.csmc.edu/7133.htmlSinai Medical Center, www.csmc.edu/7133.html 33 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Vertebral Anatomy:Vertebral Anatomy: Overview of Thoracic VertebraeOverview of Thoracic Vertebrae http://www.spineuniverse.com/dishttp://www.spineuniverse.com/dis playarticle.php/article1286.htmlplayarticle.php/article1286.html Vertebral Body Vertebral Body Lamina Spinous Process Spinous Process Pedicle Pedicle Transverse Process 44 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Vertebral Anatomy:Vertebral Anatomy: Overview of FacetsOverview of Facets Superior Articular Facet Superior Articular Facet Transverse Costal Facet Transverse Costal Facet Inferior Costal Facet Superior Costal Facet http://www.spineuniverse.com/dishttp://www.spineuniverse.com/dis playarticle.php/article1286.htmlplayarticle.php/article1286.html 55 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD For Comparison…For Comparison… http://www.spineuniverse.com/dishttp://www.spineuniverse.com/dis playarticle.php/article1286.htmlplayarticle.php/article1286.html 66 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Normal Normal FrontalFrontal RadiographRadiograph PACS, BIDMCPACS, BIDMC Spinous Processes Pedicles Intervertebral Disc Space •• Need to Assess: Need to Assess: •• Quality ControlQuality Control •• Soft TissuesSoft Tissues •• AlignmentAlignment •• BonesBones •• CartilageCartilage 77 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Normal Lateral Normal Lateral RadiographRadiograph Vertebral Body Pedicle Spinous Process Intervertebral Disc Space PACS, BIDMCPACS, BIDMC 88 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Spinal ColumnsSpinal Columns 1.) 1.) Anterior columnAnterior column –– Anterior longitudinal ligament, anterior half of the Anterior longitudinal ligament, anterior half of the vertebral body, disc, and annulusvertebral body, disc, and annulus 2.) 2.) Middle columnMiddle column –– Posterior half of the vertebral body, disc, and Posterior half of the vertebral body, disc, and annulus, and the posterior longitudinal ligament annulus, and the posterior longitudinal ligament 3.) 3.) Posterior columnPosterior column –– Facet joints, Facet joints, ligamentumligamentum flavumflavum, the posterior , the posterior elements and the interconnecting ligaments.elements and the interconnecting ligaments. Panjabi et al. 1995Panjabi et al. 1995 99 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Spinal ColumnsSpinal Columns Anterior Column Middle Column Posterior Column PACS, BIDMCPACS, BIDMC 1010 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Spinal ColumnsSpinal Columns •• The spinal canal and cord are located in the The spinal canal and cord are located in the Posterior Column, adjacent to the Middle Posterior Column, adjacent to the Middle ColumnColumn •• Therefore, fractures in elements in the Middle Therefore, fractures in elements in the Middle or Posterior Columns have the potential to or Posterior Columns have the potential to impinge on the spinal canal and cordimpinge on the spinal canal and cord •• For this reason, Middle and Posterior Column For this reason, Middle and Posterior Column fractures are considered unstable. fractures are considered unstable. 1111 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Types of FracturesTypes of Fractures Type of FractureType of Fracture Column AffectedColumn Affected Stable vs. UnstableStable vs. Unstable Compression/Wedge Compression/Wedge Anterior OnlyAnterior Only StableStable FractureFracture Burst fracturesBurst fractures Anterior and MiddleAnterior and Middle UnstableUnstable Fracture/Dislocation Fracture/Dislocation Anterior, Middle, Anterior, Middle, UnstableUnstable InjuryInjury PosteriorPosterior Seat belt fracturesSeat belt fractures Anterior, Middle,Anterior, Middle, UnstableUnstable PosteriorPosterior http://www.spineuniverse.com/displayarticle.php/article1441.html 1212 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Patient LIPatient LI •• Patient LI, an 82 year old female with Patient LI, an 82 year old female with osteoporosis and mild dementia, presented to osteoporosis and mild dementia, presented to her physician with lower back pain and her physician with lower back pain and posterior leg painposterior leg pain •• Back pain present for 1Back pain present for 1--2 months2 months •• Difficulty getting out of bed in morning due to Difficulty getting out of bed in morning due to painpain •• Loss of appetite because of intensity of painLoss of appetite because of intensity of pain 1313 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Patient LIPatient LI •• Given that Patient LI had Given that Patient LI had osteoporosis, her physician suspected osteoporosis, her physician suspected she had a compression fracture.she had a compression fracture. 1414 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Compression FracturesCompression Fractures •• Osteoporosis is the leading cause of vertebral Osteoporosis is the leading cause of vertebral compression fractures in the U.S.compression fractures in the U.S. •• 700,000 per year in U.S.700,000 per year in U.S. •• Affect 25% postmenopausal womenAffect 25% postmenopausal women •• Incidence expected to increase fourfold in next 50 Incidence expected to increase fourfold in next 50 yearsyears •• Why Important?Why Important? –– Pain can lead to immobility and further disabilityPain can lead to immobility and further disability –– 15% increased mortality rate15% increased mortality rate –– Preventable in most casesPreventable in most cases Old et al., 2004Old et al., 2004 1515 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Compression FracturesCompression Fractures •• Most commonly occur T8Most commonly occur T8--L4L4 •• Anterior or lateral flexion causes Anterior or lateral flexion causes failure of failure of Anterior columnAnterior column onlyonly •• Middle columnMiddle column and and Posterior column Posterior column are undisruptedare undisrupted •• Middle columnMiddle column may act as hingemay act as hinge •• Can be further classified by the Denis Can be further classified by the Denis Classification according to endplate Classification according to endplate involvementinvolvement P M A PACS, BIDMCPACS, BIDMC 1616 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Differential DiagnosisDifferential Diagnosis •• AtraumaticAtraumatic Compression Fracture: Compression Fracture: –– Osteoporosis Osteoporosis •• Senile/PostSenile/Post--Menopausal Menopausal •• SteroidsSteroids –– OsteomalaciaOsteomalacia –– PagetsPagets DiseaseDisease –– Multiple MyelomaMultiple Myeloma –– HyperparathyroidismHyperparathyroidism CedarsCedars--Sinai Medical Center, www.csmc.edu/7133.htmlSinai Medical Center, www.csmc.edu/7133.html 1717 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD What is your initial imaging test of What is your initial imaging test of choice?choice? •• Plain frontal and lateral radiographs are the Plain frontal and lateral radiographs are the initial studies of choiceinitial studies of choice •• In 20In 20--30% cases multiple fractures are present30% cases multiple fractures are present •• Important to image entire spineImportant to image entire spine 1818 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Radiograph Findings of Radiograph Findings of Compression FracturesCompression Fractures •• Anterior height of vertebral body is diminishedAnterior height of vertebral body is diminished •• Posterior height of vertebral body is normalPosterior height of vertebral body is normal •• No anterior or posterior translation of vertebral No anterior or posterior translation of vertebral bodiesbodies •• If anterior compression is >40% when If anterior compression is >40% when compared to posterior vertebral body height, compared to posterior vertebral body height, suspect burst fracturesuspect burst fracture 1919 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Patient LI: Patient LI: Frontal Plain Frontal Plain Radiograph Radiograph •• DextroscoliosisDextroscoliosis centered centered around L2around L2--33 •• Multilevel degenerative Multilevel degenerative changeschanges •• Endplate sclerosisEndplate sclerosis •• Multilevel facet Multilevel facet hypertrophyhypertrophy •• Increased Increased lucencylucency in in vertebral bodiesvertebral bodies •• Compression fracture of Compression fracture of L1L1 PACS, BIDMCPACS, BIDMC 2020 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Patient LI: Lateral Patient LI: Lateral RadiographRadiograph PACS, BIDMCPACS, BIDMC • Compression Compression fracture of thefracture of the L1 L1 vertebrae causing vertebrae causing focal focal kyphosiskyphosis •• There is a 5 mm There is a 5 mm anterolisthesisanterolisthesis of L5 on S1of L5 on S1 Compression Compression Fracture of L1Fracture of L1 Normal Normal L2L2 2121 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Comparison A: Comparison A: Lateral RadiographLateral Radiograph •• 71 year old with a history of 71 year old with a history of osteopeniaosteopenia who presented with who presented with midmid--lower back painlower back pain Courtesy Dr. Yamada, BIDMCCourtesy Dr. Yamada, BIDMC Normal T12Normal T12 Compression Compression Fracture of T11Fracture of T11 •• Compression fracture of Compression fracture of anterior of the T11 vertebral anterior of the T11 vertebral bodybody •• Demineralization Demineralization presentpresent 2222 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Comparison B: Comparison B: Lateral RadiographLateral Radiograph •• 82 year old who 82 year old who suffered a mechanical suffered a mechanical fall at her assisted living fall at her assisted living homehome •• There is approximately There is approximately a 15% loss of anterior a 15% loss of anterior vertebral body height of vertebral body height of T12T12 Courtesy Dr. Yamada, BIDMCCourtesy Dr. Yamada, BIDMC Compression Compression Fracture of T12Fracture of T12 2323 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Role of Additional ImagingRole of Additional Imaging •• Role of CT:Role of CT: •• Use to identify fractures not well visualized on plain filmUse to identify fractures not well visualized on plain film •• Allows for visualization of middle and posterior elementsAllows for visualization of middle and posterior elements •• Can distinguish between compression fracture and burst fractureCan distinguish between compression fracture and burst fracture •• Can also reveal spinal canal narrowingCan also reveal spinal canal narrowing •• Disadvantage: Disadvantage: •• Can’t detect horizontal fractures of vertebral bodies or pedicleCan’t detect horizontal fractures of vertebral bodies or pedicles s wellwell •• Role of MRI:Role of MRI: •• Recommended when patient has suspected spinal cord Recommended when patient has suspected spinal cord compression or other neurologic symptomscompression or other neurologic symptoms Old et al., 2004Old et al., 2004 2424 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Patient LIPatient LI •• Given that Patient LI reported posterior leg Given that Patient LI reported posterior leg pain, her physician decided to order an MRI to pain, her physician decided to order an MRI to assess the spinal cord and spinal canalassess the spinal cord and spinal canal 2525 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Patient LI: T2 MRI Patient LI: T2 MRI PACS, BIDMCPACS, BIDMC SagittalSagittal Axial Axial 2626 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Patient LI: MRI FindingsPatient LI: MRI Findings •• The The conusconus terminates at L1 terminates at L1 •• No evidence for internal No evidence for internal expansileexpansile massmass •• DextroscoliosisDextroscoliosis of the of the lumbosacrallumbosacral spine with spine with apex at L2/3 apex at L2/3 •• L1 compression fracture L1 compression fracture •• Spinal Spinal stenosisstenosis 2727 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD Treatment OptionsTreatment Options •• NonNon--operative treatment is the standardoperative treatment is the standard –– Pain medication (observe bowel motility)Pain medication (observe bowel motility) –– Brief rest (2Brief rest (2--3 days), encourage early ambulation3 days), encourage early ambulation –– Avoid compression overloads for 2 monthsAvoid compression overloads for 2 months –– Muscle relaxants, external back braces, and Muscle relaxants, external back braces, and physical therapy may also help physical therapy may also help •• If patients do not respond to conservative If patients do not respond to conservative txtx:: –– PercutaneousPercutaneous VertebroplastyVertebroplasty –– KyphoplastyKyphoplasty Singh et al., 2006Singh et al., 2006 2828 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD SummarySummary •• Compression fractures common in elderly populationCompression fractures common in elderly population •• Compression fractures are caused by failure of the Compression fractures are caused by failure of the anterior column onlyanterior column only •• Initial imaging modality of choice is plain filmInitial imaging modality of choice is plain film •• Can use CT or MRI if have concern that the middle Can use CT or MRI if have concern that the middle or posterior columns are involved, and to evaluate or posterior columns are involved, and to evaluate spinal cordspinal cord •• Treatment is usually conservativeTreatment is usually conservative 2929 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD ReferencesReferences •• De De SmetSmet AA, Robinson RG, Johnson BE, AA, Robinson RG, Johnson BE, LukertLukert BP. Spinal Compression BP. Spinal Compression Fractures and Osteoporotic Women: Patterns and Relationship to Fractures and Osteoporotic Women: Patterns and Relationship to HyperkyphosisHyperkyphosis. . RadiologyRadiology 1988; 166:4971988; 166:497--500. 500. •• KrothKroth PJ, Murray MD, McDonald CJ. PJ, Murray MD, McDonald CJ. UndertreatmentUndertreatment of osteoporosis in women, of osteoporosis in women, based on detection of vertebral compression fractures on chest rbased on detection of vertebral compression fractures on chest radiography. adiography. Am J Am J GeriatrGeriatr PharmacotherPharmacother 2004; 2(2):1122004; 2(2):112--118. 118. •• Old JL, Calvert M. Vertebral Compression Fractures in the ElderlOld JL, Calvert M. Vertebral Compression Fractures in the Elderly. y. Am Am AcadAcad FamFam PhysPhys 2004: 69(1):1112004: 69(1):111--116.116. •• Panjabi MM, Panjabi MM, OxlandOxland TR, TR, KifuneKifune M, M, ArandArand M, M, WenWen L, Chen A. Validity of the L, Chen A. Validity of the threethree--column theory of column theory of thoracolumbarthoracolumbar fractures. fractures. SpineSpine 1995; 20(10):11221995; 20(10):1122--1127.1127. •• Singh AK, Singh AK, PilgramPilgram TK, TK, GilulaGilula LA. Osteoporotic Compression Fractures: Outcomes LA. Osteoporotic Compression Fractures: Outcomes after Single versus Multipleafter Single versus Multiple--Level Level PercutaneousPercutaneous VertebroplastyVertebroplasty. . RadiologyRadiology 2006; 2006; 238(1):211238(1):211--220.220. •• YuhYuh WT, WT, ZacherZacher CK, CK, BarloonBarloon TJ, Sato Y, TJ, Sato Y, SickelsSickels WJ, Hawes DR. Vertebral WJ, Hawes DR. Vertebral Compression Fractures: Distinction between Benign and Malignant Compression Fractures: Distinction between Benign and Malignant Causes with Causes with MR Imaging. MR Imaging. RadiologyRadiology 1989; 172:2151989; 172:215--218.218. 3030 Eleanor AdamsEleanor Adams Gillian Lieberman, MDGillian Lieberman, MD AcknowledgementsAcknowledgements •• Special Thanks to:Special Thanks to: •• Gillian Lieberman, MDGillian Lieberman, MD •• Maryellen Sun, MDMaryellen Sun, MD •• Kei Yamada, MDKei Yamada, MD •• Pamela Pamela LepkowskiLepkowski •• Larry BarbarasLarry Barbaras Compression Fractures Overview Vertebral Anatomy:�Overview of Thoracic Vertebrae Vertebral Anatomy:�Overview of Facets For Comparison… Normal Frontal�Radiograph Normal Lateral Radiograph Spinal Columns Spinal Columns Spinal Columns Types of Fractures Patient LI Patient LI Compression Fractures Compression Fractures Differential Diagnosis What is your initial imaging test of choice? Radiograph Findings of �Compression Fractures Patient LI: Frontal Plain Radiograph Patient LI: Lateral Radiograph Comparison A: Lateral Radiograph Comparison B: Lateral Radiograph Role of Additional Imaging Patient LI Patient LI: T2 MRI Patient LI: MRI Findings Treatment Options Summary References Acknowledgements