3: Degenerative Spinal Disease

Question 1

Whats some general information on Degenerative Spinal Disease?
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Answer 1

Seen in up to 45% of asymptomatic adults
Four joints affected:
− Apophyseal (facet)
− Uncovertebral (V on Luschka)
− IVD (DDD, Spondylosis/Spondylosis Deformans)
-Spondylosis (Spondylosis is a term referring to degenerative osteoarthritis of the joints between the center of the spinal vertebrae and/or neural foramina)
-spondylosis deformans –> Spondylosis deformans is a condition that affects the vertebral bones of the spine and is characterized by presence of bony spurs or ‘osteophytes’ along the edges of the bones of the spine. A bony spur may develop in a single spot on the spine; more commonly, there will be multiple bone spurs in several different locations along the spine. The most common places that spondylosis deformans lesions develop are along the thoracic vertebrae (chest), especially at the junction between the rib cage and the abdomen, in the lumbar spine (lower back) and in the lumbosacral spine (around the hips and back legs). In some cases the bony spurs may become large enough that they appear to form a complete bridge between adjacent vertebral bones.
− Costal (Costovertebral, Costotransverse)

Question 2

What are the radiographic signs of degenerative Spinal Disease in the cervical spine
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pg 964

Answer 2

A. Intervertebral Disc
− C5/C6 most common
− Disc height loss, osteophytes, sclerosis
• Most reliable sign of DDD is disc height loss
-occasional sign is vacuum phenomenon-more in lumbar spine. (973)
-pseudofracture, split vertebral body (from sclerosis of unicinate process -uncovertebral arthritis)
−AP will show initial sharpening of unicinate process, with progressive bulbous enlargements
-intradiscal radiolucency-968
-intercalary bone-968
Possible instability, flex/ext studies
− Ant. osteophytes large, pt. may have dysphagia
− Post. osteophytes are usually small, but can cause
stenosis
− C5/C6 <12mm in canal = stenosis (82% rule)
− Sclerosis may extend to midbody (hemispherical)
− Intercalary bone, Ca++ of annular fibers may be an
early sign
− Vacuum may be present at the disc anteriorly as an
early sign

B. Apophyseal Joints
− Facet arthrosis
− Usually lower C-spine
− Lateral view, see loss of joint space, sclerosis, osteophytes, anterolisthesis
− AP projection, see sclerosis and hypertrophy of pillars

C. Uncovertebral Joints
− Uncovertebral arthrosis
− Lower segments, especially C5/C6
− Posterolateral vertebral body, ant. IVF
− Blunting and/or hypertrophy of uncinate seen on
AP view
− IVF narrowing, lateral stenosis seen of oblique
view
− Pseudofracture appearance seen on lateral view

Question 3

what are the radiographic features of DJD in the thoracic spine?
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968-images

Answer 3

A. Intervertebral Disc
− Spondylosis, DDD
− Less pronounced than other regions
− Disc height normally decreases in the cephalad direction, T2/T4 narrowest
− Anterior, or lateral osteophytes (which tend to be small and right-sided),
sclerosis, disc narrowing

B. Costal Joints
− Costotransverse/costovertebral arthrosis
− Lower segments most common (T9 & T10)
− Bony hypertrophy, osteophytes, sclerosis, loss of joint space. − May simulate a lung mass on lateral chest view
− May simulate upper GI disease symptoms

C. Apophyseal Joints − Uncommon
− Seen best on AP, sclerosis

Question 4

What are the radiographic signs o DJD in the lumbar spine?
12 ipad
971 text

Answer 4

A. Apophyseal Joints − Facet arthrosis
− Most common at L4/L5
− Loss space, sclerosis, osteophytes/hypertrophy
− Degenerative anterolisthesis (may be only obvious finding) − Best seen on AP or oblique views
− Stress studies can be done to assess for instability

B. Intervertebral Disc
− Most common at L4/L5, L5/S1
− Best seen on LATERAL view
− DDD, IVOC or spondylosis deformans
− Disc height loss, sclerosis, vacuum cleft or phenomenon, alignment altered,
osteophytes

1. Types of Osteophytes
   Traction
   − Approx. 2mm length
   − Horizontal, tapered end Claw
   − Broader base
   − Horizontal, climb vertical − Curvilinear, tapered end
   CHI303 Radiology Notes 9
   V.
   Advanced Imaging of the Degenerative Motion Segment − Assessment with MRI best for most situations
   − Loss of signal on T2, due to loss of H2O
   − Loss first seen at anterior 2/3rds of the disc
   − Lose disc height, after signal changes; osteophyte formation seen with long term disease − Disc displacement types:
   a) Disc bulge b) Disc protrusion c) Disc extrusion d) Sequestration
   A. Disc Bulge
   − Circumferential, broad-based displacement (>50% disc circumference)
   − Part of natural aging with DDD
   − See loss of disc signal
   − Typically symmetric with maximal bulge midline
   − Various etiologies, including degeneration, variants, bone remodeling, and
   artifacts (illusions) B. Disc Protrusion
   − Focal (<50%) migration of nuclear material contained CHI 303 Radiology Notes
2. Spondylosis Deformans
   − Breakdown at outer annular
   attachment to body
   − MINIMAL LOSS DISC HEIGHT
   WITH LARGE OSTEOPHYTES
   − Osteophytes are CLAW type
   − Milder cases termed spondylosis

3.
-Intervertebral Osteochondrosis (IVOC) 
-Small osteophytes (traction)
-LOSS OF DISC HEIGHT WITH SEVERE
ENDPLATE SCLEROSIS
− Schmorl’s node formation
− Vacuum phenomenon typically seen
− Milder cases termed degenerative disc disease

• Increased density of articular processes
• loss of joint space
• osteophytes
• sclerosis
• facet arthrosis
• spondylolisthesis (anterolisthesis)

Question 5

What is the best way to image a degenerative motion segment?
-were are the losses seen in DJD spine
-what are the 4 disc displacement types?
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Answer 5

− Assessment with MRI best for most situations
− Loss of signal on T2, due to loss of H2O
− Loss first seen at anterior 2/3rds of the disc
− Lose disc height, after signal changes; osteophyte formation seen with long term disease − Disc displacement types:
a) Disc bulge b) Disc protrusion c) Disc extrusion d) Sequestration

Question 6

Disc displacement types
a) Disc Buldge
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Answer 6

− Circumferential, broad-based displacement (>50% disc circumference)
− Part of natural aging with DDD
− See loss of disc signal
− Typically symmetric with maximal bulge midline
− Various etiologies, including degeneration, variants, bone remodeling, and
artifacts (illusions)

Question 7

Disc displacement types
b) Disc protrusion
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Answer 7

− Focal (<50%) migration of nuclear material contained
by outer annulus
− Maximum width of herniated material is no greater than base of herniation
− Cord myelopathy can result from large protrusions
− T1W shows disc material past vertebral margins, with signal hyperintense to
CSF. Can be anterior, but these are of questionable significance as adjacent structures can displace away from the disc

Question 8

Disc displacement types

c) Disc Extrusion

Answer 8

− Maximum width of herniated material is greater than base of herniation in any
plane.
− Disc material remains attached, but may not be contained by annulus
− Contained extrusion – outer annulus/PLL walls off material
− Non-contained extrusion – extends through annulus and possibly PLL. May be
sub-ligamentous or trans-ligamentous (in relation to PLL).

Question 9

Disc displacement types
d) Sequestration
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Answer 9

− A subtype of extrusion, where a fragment of disc material breaks free
− Still hydrated, so can see high signal on T2W
− May migrate inferior or superior within the canal and eventually be resorbed by
the body
− Not associated with increased risk of adhesions
− Clinically, extrusions and sequestrations present and behave similarly

Question 10

What are the clinical considerations of Disc Displacement?

Answer 10

− Need clinical correlation - value of MRI diminishes without this
− Abnormal disc can be seen in approximately 20% asymptomatic population
− Cauda Equina Syndrome
− Back/leg pain, urinary bladder incontinence, numbness, impotency − SURGICAL EMERGENCY !!