Let’s start with a case
An 80-year-old male was admitted to the hospital for 1 day with Low back pain and limitation of movement caused by a fall.
Physical examination: positive pressure pain in the thoracolumbar segment and positive longitudinal percussion pain. Auxiliary examination: old fracture of thoracic 12 vertebrae and compression fracture of lumbar 1 vertebrae, the films of which are shown below.
A balloon dilatation vertebroplasty of the lumbar 1 vertebral body under local anesthesia was performed on the second day of admission.
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The picture shows a fracture in the middle of the lower endplate of the lumbar 1 vertebral body (white arrow), a low signal area seen in the middle and posterior part of the vertebral body (red arrow), and a high signal in the thoracic 12 vertebral body consistent with a fat-filled bone marrow sinus (yellow arrow).
There is no disagreement with the diagnosis of osteoporotic compression fracture of the vertebral body in this case, and there is no disagreement with the lumbar 1 vertebral body as the responsible vertebral body for the fresh fracture from the MRI and CT, but it is still easy to make mistakes specifically in the surgical judgment.
Clinical misclassification of the responsible vertebral body or gap is not uncommon
In this case, it is easy to mistake the thoracic 12 vertebrae for the lumbar 1 vertebrae from the orthopantomogram. This is especially true when the thoracic 12 vertebra is an old fracture and the vertebral body has a compressed morphology.
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Many times we focus on several variants of the lumbar spine – “lumbar sacralization”, “sacral lumbarization”, and “thoracic lumbarization” – and sometimes we feel more confused when we have to identify them. In fact, if we clear the clouds, why should we care about the variants and just grab the responsible vertebrae?
A freshly fractured vertebra is very clear on the MRI, but when it is “projected” onto the X-ray, it is easy to misjudge it because we are used to determining which vertebra is which from the rib and iliac spine patterns, for example, the thoracic spine has ribs, and the high point of the iliac spine is opposite the lumbar 4-5, but these are not always accurate.
So how is the responsible vertebra or responsible gap determined?
The author counts the responsible vertebra or responsible gap from the lateral radiographs and X-rays, which definitely correspond to each other. After the responsible vertebra or responsible gap is determined on the lateral X-ray, then the position of the iliac spine is used to determine the responsible vertebra or responsible gap on the orthopantomograph.
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In this case, for example, the responsible vertebra seen on the MRI corresponds on the lateral X-ray, which is easy to find (red arrow), and then look at the location of the high point of the iliac spine on the lateral film (purple arrow). Then go to the orthopantomograph and count from the iliac spine high point position, so that you can completely exclude the interference from various variants.
In the lateral radiograph below, the responsible vertebra is the third vertebra above the iliac spine high point. So back to the orthopantomogram, we also count three vertebrae up from the high point of the iliac spine on the orthopantomogram, and it must be the responsible vertebra.
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In a nutshell: CT MRI can’t be wrong, and lateral spine films must correspond to CT MRI, so it’s okay to count from the intervertebral space, in the following order: CT MRI – lateral spine film – orthogonal spine film (judged by the highest point of the iliac crest). The order: CT MRI – lateral spine film – orthogonal spine film (determined by the highest point of the iliac crest) .
Moderator @Rafenbank General Manager has added
It is easy to make a vertebral body positioning error (wrong count) and must be counted orthogonally and laterally repeatedly. The lateral position should not only be counted, but also further determined by the morphology of the vertebral body, especially in this part before the puncture needle, balloon support or cement injection.
In most cases, one or even two views of the C-arm are not counted. We use a 20 ml syringe needle inserted percutaneously along the midline for positioning, which ensures that the C-arm moves from the bottom to the top and is not lost in the count.
What are the variants of the spine?
Let’s see what the moderator of @Hua Xia Yuan Xiong has to say.
Spinal developmental malformations can be limited to developmental abnormalities of the spine, or can be part of a systemic congenital developmental abnormality, such as mucopolysaccharidosis, congenital chondrodysplasia, spinal epiphyseal dysplasia, etc.; or part of other congenital abnormalities, such as skull base depression (this disease is mostly due to congenital developmental abnormalities of the atlanto-axial spine and occipital bone, resulting in upward depression of the skull base and upward displacement of the dentate process. It is often combined with craniocervical junctional deformities such as atlanto-occipital ossification and atlanto-occipital ossification).
It is limited to the developmental abnormalities of the spine and is generally not accompanied by abnormalities of intelligence, etc. The common ones are:
I. Congenital abnormalities of curvature, such as scoliosis deformity and retroflexion bending deformity of the spine.
II. Developmental defects of the vertebral body.
- poor segmentation: the most common is the migrating vertebrae, the total number of vertebrae inconvenient, just a certain number of vertebrae increased or decreased, the most common missegmentation between the lumbosacral vertebrae; in addition, such as congenital fusion vertebrae, most often occurs in the neck, also known as short neck syndrome, that is, Klippel-Feil syndrome.
- poorly formed vertebrae.
(1) hemivertebrae: unilateral formation of hemivertebrae can lead to scoliosis; posterior hemivertebrae can lead to retroversion of the spine.
(2) cleft vertebrae: if the spinal cord remains in the vertebral body, it can form the anterior and posterior halves of the vertebral body, more common left and right halves of the vertebral body, also known as butterfly vertebrae.
(3) abnormal accessory development.
Commonly seen are spina bifida (recessive spina bifida and dominant spina bifida, mostly occurring in the lumbosacral region), collapse of the vertebral arch with slippage (mainly seen in the lumbar spine), etc.
How are thoracic lumbarization, sacral lumbarization, and lumbar sacralization determined?
The responsibility gap is clear and the success of the surgery is most important, but these terms should also be understood ?
Lumbar sacralization: refers to the transformation of all or part of the 5th lumbar vertebra into a sacral vertebral form, so that it forms part of the sacral block. Clinically, the 5th lumbar vertebrae are mostly found to have one or both sides of the transverse process hypertrophied into a winged shape and fused with the sacrum, and mostly form a pseudo-joint with the iliac crest; while in a few cases, the 5th lumbar vertebrae (together with the transverse process) and the sacrum are fused into one piece.
Sacralization of the lumbar spine generally has the following different conditions.
The space between the hypertrophied transverse process and the ilium is small, which produces irritation or compression of the posterior lateral branch of the 5th lumbar nerve on the nearby fascial tissue.
The hypertrophied transverse process rubs against the sacrum, producing secondary bursitis, and removal of this hypertrophied transverse process in those with pain may result in pain relief. If the hypertrophied transverse process forms a pseudo-articulation with the sacrum, it is susceptible to osteoarthritis due to the thin interarticular cartilage and friction.
The hypertrophied transverse process opens into a pseudarthrosis with the iliac bone, and the edge of the hyperplastic joint irritates the L4 or L5 nerve roots running anteriorly.
Lumbarization of the thoracic vertebrae: The 12th thoracic vertebra loses its ribs and forms a lumbar vertebral pattern, but if the 5th lumbar vertebra is not accompanied by sacral vertebralization, it still has a lumbar pattern and functions as a lumbar vertebra.
Sacral lumbarization: the 1st sacral vertebra evolves into a lumbar vertebra-like form, the incidence is very low, mostly found accidentally during the reading of the film, and generally asymptomatic.
Sacrococcygeal fusion: the sacral vertebrae and caudal vertebrae fuse with each other to form one piece, which is more common than the former.
Identification method: the transverse processes of the lumbar spine are generally “three long / four cocked / five wide”, the L3 transverse process is the longest, the L4 transverse process is generally upturned, and the L5 transverse process is the widest, which is especially useful when the thoracic lumbarization is combined with the L5 sacralization.
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