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FF_Spinal Degeneration.

Table of Contents

Anatomy, Procedure & Technical

Guidelines

Clinical

Differentials

Radiological

How to Report

Italian Consensus 2021.

Italian Radiology and Neuroradiology Associations wrote it and the Orthopaedic and Neurosurgical Associations agreed to it.1 About as good as anything else and comprehensive.

Preamble: Focussed on

  • 'Functional Spinal Units'
  • Clinical Information broken into:
    1. Only LBP without radiation.
    2. Radiated pain and its site/side
    3. Motor disorders / Sensitivity
    4. Temporality
    5. Resistance to medical therapy.
  • Report should be organised into the usual pattern and use appropriate terminology.

MAIN FINDINGS: STRUCTURE.

  1. SPINAL SKELETAL STRUCTURE
    i. Signal or skeletal structural changes.
    ii. Curvatures (= maintenance or accentuation or reversal of physiological ones).
    iii. Vertebral alignment (maintained or not).
  2. SPINAL FUNCTIONAL UNITS
    1. DISCO-SOMATIC UNITS
      a. Disc Alterations.
      i. Pathological changes of SI and Height.
      ii. Morphological changes = Bulges etc.
      Describe location, extent and possible spinal cord & root compression.
      b. Vertebral Body / Bone Marrow Alterations.
    2. FACET JOINT AND LIGAMENTOUS APPARATUS
  3. FORAMINAL STENOSIS
  4. SPINAL CANAL STENOSIS
  5. CONUS MEDULLARIS & CAUDA EQUINA
    1. Changes in SI and location of conus and cauda.
    2. Clumping and abnormal distribution of roots.
  6. PARASPINAL SOFT TISSUES & MUSCLES
    1. Adipose infiltration of paravertebral muscle.
    2. Abnormalities of soft tissue ie lymphoedema.

MAIN FINDINGS: DETAILS

  1. SPINAL SKELETAL STRUCTURE
    1. Tumours / Infiltration / Infection / Collapses / Asymmetry
    2. Lordosis / Kyphosis = Loss of accentuation.
    3. Misalignment - in all 3 planes but mostly spondylolisthesis.
      1. Meyerding Classification.
      2. Type = (Isthmic / Degen.)
  2. SPINAL FUNCTIONAL UNIT
    1. DISCO-SOMATIC UNIT.
      1. Disc Alterations
        1. Signal (Normal / Desiccated / Calcified / Gas)
        2. Morphological Changes = Displacement beyond usual boundaries.
          1. Diffuse = diffuse displacement bulging = >90 deg or 25%.
          2. Focal = focal displacement = <25%: a
            1. Disc protrusion or
            2. Disc herniation =(extrusion|sequestration). Mention any (caudal / cranial) aspect and in sequestration mention disc material in relation to the PLL (subligamentous if intact|Extra or Transligamentous if disrupted)
          3. Use (central|paramedian|foraminal|extraforaminal) for the positions.
      2. Vertebral and Bone Marrow Alterations.
        1. Include vertebral spondylosis = irregularity and sclerosis of end plates +/- osteophytes.
          1. Can include severity grade (minimal / mild / moderate / severe) or Kellgrens.
        2. Subchondral Bone marrow = use generic osteochondrosis not a Modics if there are other more important degenerative findings.
    2. FACET JOINT & LIGAMENTOUS APPARATUS.
      1. Report these degenerative features:
        1. Arthrosis
          • irregularity, sclerosis and articular joint space narrowing, synovial thickening, joint fluid, synovial cysts.
          • severity on (minimal / mild / moderate / severe)
        2. Thickening (or 'corrugation') of ligamentum flavum.
          • Do not use 'hypertrophy' as no growth of cells but accumulation of collagen.
          • Gets thicker with age varies with level. N<= 4mm.
  3. FORAMINAL STENOSIS
    1. Use this grading system:
      1. Grade 1 (mild stenosis): <50%, perineural fat is reduced, but still surrounds root.
      2. Grade 2 (moderate stenosis) >50% stenosis, perineural fat only partially surrounds root.
      3. Grade 3 (severe stenosis) complete obliteration of foramen, pinched in the foraminal zone due to extrinsic compression.
  4. SPINAL CANAL STENOSIS
    1. Explain the causes of the canal stenosis (disc displacement/herniation/bulging/facet joint hypertrophy/thickening of ligamentum flavum/spondylolisthesis)
    2. Grade the severity without any measurements using:
      1. Grade 1 (mild stenosis): initial compression and reduction of dural sac area; cauda rootlets are clearly distinguishable;
        • In cervical and dorsal levels = <50% CSF obliteration with no spinal cord deformity.
      2. Grade 2 (moderate stenosis): cauda roots are aggregated, CSF film still surrounding them
        • In cervical and dorsal levels = >50% CSF obliteration of CSF surrounding spinal cord with early deformity, but no cord signal change.
      3. Grade 3 (severe stenosis): cauda roots appear as a bundle with no CSF surrounding and with posterior epidural fat present.
        • In cervical and dorsal levels = >50% CSF obliteration of subarachnoid space surrounding cord with compression and signal change in the cord.
      4. Grade 4 (extreme stenosis): No rootlets nor CSF nor epidural fat visible.
        • In cervical and dorsal levels = complete CSF obliteration and spinal cord compression.
    3. Specify presence of isolated stenosis of any lateral recess as well as can be responsible for radiculopathy.
    4. Clinical scenario + Grade 3 or 4 = means decompression more likely to be offered. 2. Orthopods appear not to base their decisions on area measurements but on this morphological grading.
  5. CONUS MEDULLARIS & CAUDA EQUINA
    1. Slightly puzzling why this is in here as the above grading includes changes to the cord and roots.
  6. PARASPINAL CHANGES
    1. True paraspinal changes in muscle inc (severity) fatty infiltration.
    2. Incidentals - go in the incidental box.

Papers

References

Footnotes

  1. Pizzini, F.B., Poletti, M., Beltramello, A. et al. Degenerative spine disease: Italian position paper on acquisition, interpretation and reporting of Magnetic Resonance Imaging. Insights Imaging 12, 14 (2021). https://doi.org/10.1186/s13244-020-00952-w ↩

  2. Schizas C, Kulik G (2012) Decision-making in lumbar spinal stenosis. J Bone Joint Surg Br 94-B:98–101 ↩