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MODULE 1

MODULE 1. Lumbar Spine. INTRODUCTION When to x-ray. History, persistent history, PM history, family history Chief Complaint – O, P, P, Q, R, S, T Physical examination – orthopedic, neurological Differential diagnosis Tests to limit differential diagnosis.

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MODULE 1

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  1. MODULE 1 Lumbar Spine

  2. INTRODUCTION When to x-ray • History, persistent history, PM history, • family history • Chief Complaint – O, P, P, Q, R, S, T • Physical examination – orthopedic, • neurological • Differential diagnosis • Tests to limit differential diagnosis

  3. Who gets x-ray • Risks versus benefits ratio • Cost versus benefit ratio • When differential diagnosis includes • something to: • rule in, rule out or • monitor a known condition by x-ray

  4. Shoot Series

  5. ABC’S • Technical evaluation • Search pattern

  6. Normal Anatomy

  7. Mensuration • Lumbar spine • Disc height • Hurxthal - measures mid point • of each endplate • easy • can’t account for extension or flexion malposition • distance

  8. Farfan Anterior height ratio (AHR) = Anterior height Diameter Posterior height ratio (PHR) = Posterior height Diameter DH = AHR PHR More complex posterior anterior Research use height D height

  9. Both Measurements • Great variation exists • Rotation >40o or lateral flexion >20o • leads to unreliable results

  10. Decrease disc height causes • Degeneration • Surgery (i.e. discectomy) • Chemonucleolysis • Infection • Congenital hypoplasia

  11. Poor correlation between loss of disc height and pain.

  12. IVD Angles • Lines tangential to the endplates extend • until intersection • Measuring angle • Little predictability • Alterations may occur • Antalgia • Muscle imbalance • Poor posture • Early DJD • Facet syndrome may increase angle • Disc herniation may decrease angle

  13. Lumbar Lordosis • Top of L1 and S1 used or bottom of L5 • Draw perpendicular to tangential lines • Measure angle of intersection • Great variety • 50o-60o average

  14. Lumbosacral lordosis angle and sacral inclination not useful.

  15. Lumbosacral Angle • (Sacral base angle, Ferguson’s angle) • Tangential sacral base • Horizontal line • Measure angle of intersection • 41o +/- 7o • It has been suggested that increased angle leads to increased shearing and compressive forces at the facets • No increase in anterolisthesis noted

  16. Static Vertebral Malpositions • Flexion • Extension • Lateral flexion • Rotation • Anterolisthesis • Retrolisthesis • Laterolisthesis

  17. Lumbar Gravity Line (Ferguson’s, weight bearing, Ferguson’s gravity) • Center of L3 • Plumb line • Should intersect anterior sacral margin • +/- 10mm

  18. McNab’s Line • High number’s of asymptomatic patients make this line’s usefulness doubtful • Was originally used on recumbent films weight bearing may alter utility

  19. Hadley’s Curve • AP and obliques views used • Interuption of the line may • indicate: • Rostral/caudal migration • Extension malposition • Rotational malposition

  20. VanAkkerveeken and flexion and extension have been largely replaced by the more sensitive comp/distraction study.

  21. Lateral Bending Study • May suggest ligament laxity and/or muscle • spasm • Poor correlation between this and clinical • picture

  22. Meyerding • Replaced by the more useful percentage • method • Anteriority  sacral base length = % of antero

  23. Ullmann’s Line • Tangential to sacral base • Perpendicular to and coincide with • anterior sacral prominence • L5 should be at or posterior to line, if • anterior, it represents anterolisthesis • Note:decreased lordosis may produce • false positive

  24. Interpediculate Distribution and Eisenstein’s and canal body ratio (unreliable) measure for central canal stenosis Small numbers are suggestive only CT, MR for definitive diagnosis

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