This document discusses imaging of the lumbar spine. It begins with an introduction and overview of spine nomenclature and the evidence for imaging. Key points include prevalence data for common disc findings in asymptomatic individuals. The document also reviews rationales for imaging, such as ruling out red flag conditions or confirming treatable abnormalities like stenosis or herniated discs. Consensus nomenclature is presented for describing lumbar disc findings.

1. Imaging Degeneration of the
Lumbar Spine:
THE 1 LESSONS
ST
Hieder A`ala
601
MUST

2. Course Outline
• Introduction,
Nomenclature, Evidence
for Imaging
• Natural History and
Prognosis
• New Techniques

3. Spine Nomenclature and
Evidence for Imaging

4. Talk Objectives
• “Background”
• Nomenclature for disc findings
• Who should be imaged-
evidence basis?

5. 15 Century Turkish
th
Treatment- Cauterization

6. 21st Century American
Treatment

8. Frequency of Back Pain Types
2% visceral 1% tumor,
infection,
inflammatory
arthritis
97%
“mechanical”

9. “Mechanical” Causes of
Low Back Pain
• Lumbar strain, sprain (70%)
• Degen (disc and facets) (10%)
• Herniated disc (4%)
• Spinal stenosis (3%)
• Osteoporotic comp fracture (4%)

10. The Least We Can Do:
Speak the Same Language
Nomenclature for disc findings

11. Consensus Nomenclature

12. Question???
• What is the ASNR/NASS
nomenclature for describing
lumbar discs?

13. Consensus Nomenclature
• normal
• degeneration
• anular tears
• herniation

14. Consensus Nomenclature
• normal
–well hydrated disc
–central dark band= central
fibrosus
age-related changes=NOT normal

15. Intranuclear Cleft

16. Normal

17. Consensus Nomenclature
• normal
• degeneration
–desiccation
–narrowing
–bulging
–endplate changes
–osteophytes

18. Glossary of disc
pathology terms
• Herniation: nonspecific term subject to misinterpretation.
– Not recommended.
• Bulge: diffuse enlargement of disc area
– Very common
– Usually not clinically important
– May contribute to spinal stenosis
• Protrusion: nucleus pulposis pushes focally through
fibers of annulus fibrosis
– Base wider than apex
– May focally impinge on nerve or thecal sac

19. Glossary of disc
pathology terms
• Extrusion: nucleus material pushes out beyond
posterior longitudinal ligament but remains in contact
with disc space
– Apex wider than base
– Likely to impinge on nerve roots
• Sequestration: Disc fragment isolated from parent
disc

20. Glossary of disc
pathology terms
• Localizing terms:
–Central
–Paracentral
–Foraminal
–Lateral

21. Disc Degeneration
Desiccation Narrowing

22. Disc Degeneration:
Findings?
Narrowing
Osteophytosis
Vacuum Disc
Endplate sclerosis

23. Bulging

24. Consensus Nomenclature
• normal
• degeneration
• anular tear=anular fissure (high
intensity zones=HIZ)
• herniation

25. Degeneration and Tears

26. Degeneration and Tears

27. Degeneration and Tears

28. Consensus Nomenclature
• Herniation
– localized displacement of disc
o
>50% (180 ) = bulge
<50% = herniation

29. Consensus Nomenclature
• normal
• degeneration
• anular tears
• herniation
–protrusion
–extrusion

30. Disc
Normal Bulge
Bony
Endplate Canal
Protrusion Extrusion

31. Disc Classification

32. Protrusion

33. Protrusion

34. Extrusion

35. Extrusion

36. Extrusion

37. Extrusion

38. Classification of Nerve
Root Condition
• Normal
• Contacted
• Displaced
• Compressed

39. Normal Nerve Roots

40. Contacted Nerve Root

41. Contacted Nerve Root

42. Displaced Nerve Root

43. Compressed Nerve Root

44. Displaced and
Compressed Nerve Root

45. Displaced and
Compressed Nerve Root

46. Talk Objectives
• “Background”
• Nomenclature for disc findings
• Who should be imaged-
evidence basis?

47. Prevalence of Disc Findings in Subjects without LBP
100%
80%
64%
60%
40%
32%
20%
6%
0%
Bulge
bulge
Protrusion
protrusion
Extrusion
extrusion

48. Disc Degeneration
• Signal loss on T2-weighted
images
• Height loss

49. Disc Degeneration

50. Disc Degeneration

51. Anular Tear

52. Take Home Points
Regarding Prevalence
• many imaging findings are
common in asx’s
• certain findings are related to
prior low back pain and more
likely to be clinically important
–extrusions, root comp, stenosis

53. Rationale for Imaging
• r/o low prob red flag condition
• rule-in treatable conditions
–stenosis
–herniated disc
–spondyloarthropathy
?
–instability

54. Early Imaging Red
Flags
• ? Fx
–h/o major trauma
–minor trauma in older or
osteoporotic pt

55. Red Flags
• age>50 or <20
• h/o malignancy
• constitutional sx
• ↑ infection risk (IVDA, HIV, etc)

56. Red Flags
• possible cauda equina syndrome
–saddle anesthesia
–urinary retention
–severe/progressive neurologic
deficit in lower extremity