Acute versus Chronic Disc Bulges

Traumatic versus Chronic Disc Bulges

 

There are many criteria that can be used to distinguish acute versus chronic disc bulges and traumatic versus chronic disc bulges.  Below are some of the more important ones:

 

 

 

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Reference Articles

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Br J Neurosurg. 2007 Apr;21(2):224-7.

 

The radiographic evolution of a Schmorl's node.

Park P, Tran NK, Gala VC, Hoff JT, Quint DJ.

Source

Department of Neurosurgery, University of Michigan Health System, Ann Arbor, MI 48109-0338, USA. This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Abstract

We present a case showing the development of a Schmorl's node from its acute to chronic stage by serial MRI. In contrast to the mature Schmorl's node, imaging characteristics of the acute Schmorl's node have not been well-illustrated, particularly by contrast-enhanced images at various stages of development.

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Spine (Phila Pa 1976). 1998 Nov 1;23(21):2272-5.

 

The pathogenesis of Schmorl's nodes in relation to acute trauma. An autopsy study.

Fahey V, Opeskin K, Silberstein M, Anderson R, Briggs C.

Source

Victorian Institute of Forensic Medicine, Department of Forensic Medicine, Monash University, Southbank, Victoria, Australia.

Abstract

STUDY DESIGN:

Seventy thoracolumbar spines from cadavers of individuals killed in motor vehicle accidents were examined pathologically and radiologically, particularly for the occurrence of acute Schmorl's nodes.

OBJECTIVES:

To document whether Schmorl's nodes occur acutely as a result of trauma.

SUMMARY OF BACKGROUND DATA:

Theories proposed to explain the pathogenesis of Schmorl's nodes include developmental, degenerative, traumatic, and disease influences. Few studies show a direct causal relation between a traumatic episode and acute Schmorl's node formation.

METHODS:

Thoracolumbar spines were removed at autopsy, underwent radiography in the anteroposterior and lateral planes, fixed, sagittally cut, and underwent radiography a second time. Pathologic and radiographic examinations were performed.

RESULTS:

Nine acute Schmorl's nodes were detected, most in association with other acute injuries to the spine. Most acute Schmorl's nodes were present in spines from individuals aged 11-30 years, with a male to female ratio of 9:1, and were localized to the T8-L1 region. Spines from motorcyclists showed the highest percentage of acute Schmorl's nodes. No acute Schmorl's nodes were detected radiologically.

CONCLUSION:

Schmorl's nodes do occur acutely as the result of a single traumatic episode, and are almost always associated with other acute spinal injury. The frequency and occurrence of acute Schmorl's nodes in motorcyclists suggest that axial loading is an important mechanism. Their predominance in the T8-L1 region suggests that this region is particularly susceptible to stress.

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Eur Spine J. 1995;4(1):56-9.

 

Schmorl's nodes and low-back pain. Analysis of magnetic resonance imaging findings in symptomatic and asymptomatic individuals.

Takahashi K, Miyazaki T, Ohnari H, Takino T, Tomita K.

Source

Department of Orthopaedic Surgery, Kanazawa University, Japan.

Abstract

Magnetic resonance imaging (MRI) findings in cases with symptomatic and asymptomatic Schmorl's nodes have been analysed. In all symptomatic cases, the vertebral body marrow surrounding the Schmorl's node was seen as low signal intensity on T1-weighted images and as high signal intensity on T2-weighted images. It was confirmed by histological examination that the MRI findings indicated the presence of inflammation and oedema in the vertebral bone marrow. These MRI findings were not seen in asymptomatic individuals. Inflammatory changes in the vertebral body marrow induced by intraosseous fracture and biological reactions to intraspongious disc materials might cause pain. We postulate that after fracture healing and subsidence of inflammation, the Schmorl's nodes become asymptomatic, in analogy with old vertebral compression fractures. MRI is not only useful in detecting the recently developed Schmorl's nodes but also in differentiating between symptomatic and asymptomatic Schmorl's nodes.

PMID: 7749909 [PubMed - indexed for MEDLINE]

 

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American Journal of Neuroradiology 23:1105-1109, August 2002

© 2002 American Society of Neuroradiology

SPINE

Serial MR Imaging of Annular Tears in Lumbar Intervertebral Disks

Fletcher M. Muntera, Bruce A. Wassermana, Hsiu-Mei Wub and David M. Yousema

a The Johns Hopkins University School of Medicine, The Russell H. Morgan Department of Radiology and Radiological Sciences, Baltimore, MD

b Department of Radiology, Veterans General Hospital-Taipei, School of Medicine, National Yang-Ming University, Taipei, Taiwan

Address reprint requests to Fletcher M. Munter MD, The Johns Hopkins University School of Medicine, The Russell H. Morgan Department of Radiology and Radiological Sciences, Room: Phipps B-108, 600 N. Wolfe Street, Baltimore, MD 21287

BACKGROUND AND PURPOSE: Annular tears of lumbar intervertebral disks are found in both symptomatic and asymptomatic persons; therefore, it is difficult to determine whether these findings indicate acute abnormality. Our purpose was to determine whether the MR imaging findings of tears (ie, hyperintensity and contrast enhancement) of the annulus fibrosus persist or resolve over time.

METHODS: A radiologic database was searched for spinal MR imaging examinations noting annular tears. Eighteen patients were identified who had undergone more than one spinal MR imaging study. The images were reviewed for presence or absence of annular tears, defined as an area of hyperintensity on T2-weighted images or enhancement in the posterior annulus, separate from the nucleus pulposus.

RESULTS: Annular tears were observed at 29 levels in 18 patients. Two tears developed during the follow-up interval. When contrast-enhanced images were obtained during serial examinations, 10 (100%) of 10 enhancing annular tears persisted on the follow-up contrast-enhanced T1-weighted images (mean interval, 17.2 months; SD, 12.3 months). High signal intensity on T2-weighted MR images was noted in 26 (96%) of 27 tears initially and persisted in 23 (88%) of 26 (mean interval, 21.9 months; SD, 15.0 months).

CONCLUSION: Hyperintensity on T2-weighted MR images and enhancement of annular tears could not be used to determine the tears' acuity over the range of follow-up provided in this study.

 

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Semin Ultrasound CT MR. 1993 Dec;14(6):389-98.

The acute lumbar disc herniation: imaging diagnosis.

Yussen PS, Swartz JD.

Source

Department of Radiology, Hospital of the Philadelphia College of Osteopathic Medicine, Medical College of Pennsylvania 19131.

Abstract

The acute lumbar herniated nucleus pulposus (HNP) can often be diagnosed on good quality MRI or CT examination. Myelography, discography, and postmyelography/postdiscography CT ordinarily are reserved for equivocal and protracted cases. MRI is recommended as the initial study of choice except for older patients for whom CT may be more valuable because of the high incidence of osteophytosis. Patients with acute herniated nucleus pulposus (HNP) may have varied clinical symptoms depending on the level of the HNP, extent of the annulus tear/depth of penetration of nuclear material, and the direction of the disc herniation. HNP does not necessarily produce radiculopathy and may cause vague low back pain. This article reviews and analyzes the clinical symptoms and problems associated with HNP, as well as the pitfalls and differential diagnostic possibilities in interpretation.

 

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Spine (Phila Pa 1976). 2010 Feb 26. [Epub ahead of print]

Acute Injury of an Intervertebral Disc in an Elite Tennis Player: A Case Report.

Baranto A, Hellström M, Swärd L.

Source

From the Departments of *Orthopaedics and daggerRadiology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden.

Abstract

STUDY DESIGN.: A case report. OBJECTIVE.: To present a previously not described rare case of intradiscal hematoma due to acute trauma in an elite tennis player. SUMMARY OF BACKGROUND DATA.: Several studies have demonstrated a high frequency of radiological changes in the spine of athletes, especially in sports with high loads on the back. Signs of disc degeneration without disc herniation have frequently been found in magnetic resonance imaging (MRI) studies of the spine of athletes. It has also been shown that radiological abnormalities of the spine in young athletes are correlated to back pain. METHODS.: An elite male tennis player experienced pain in the right buttock after a backhand stroke. He was successfully treated for hip problems and started to play competitive tennis, 2 weeks later. After few games, a backhand stroke again resulted in intense pain projected in the os coccyx region. At examination, there were no neurologic disturbances. At palpation over the spinal processes (Springing test) of L1-L2, the patient experienced intense pain projected to the os coccyx region. RESULTS.: MRI examination showed an injured L1-L2 disc with fluid inside the disc with a signal similar to blood. Four additional MRI examinations were performed 2 weeks and 2 years after the injury until disc degeneration is formed. Radiograph examination before and 2 years after the injury is available. CONCLUSION.: In conclusion, trauma in athletes can cause intradiscal hematoma, which probably is a new etiology for disc degeneration. Also that sudden onset of pain in the hip or the gluteal region may be caused by referred pain due to a disc lesion. Intradiscal hematoma can be visualized using MRI.

 

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Eur J Radiol. 2009 May;70(2):352-6. Epub 2008 May 2.

Magnetic resonance imaging of lumbar intervertebral discs in elderly patients with minor trauma.

Afzal S, Akbar S.

Source

Orthopaedic Spine Surgeon, Spine Clinic, Srinagar, Kashmir, India. This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Abstract

PURPOSE:

Vertebral body fractures due to minor trauma, which commonly occur in the elderly, are a frequently encountered clinical problem. We utilized MRI in patients with acute back pain following minor injury to ensure the earliest possible diagnosis. Lumbar discs adjacent to fractured vertebral bodies were evaluated, using magnetic resonance imaging (MRI), to elucidate how often these discs were injured and how the injured discs were depicted by MRI.

MATERIALS AND METHODS:

We retrospectively reviewed MR images of 74 discs from 37 elderly patients (>65-year-old) with a single level vertebral fracture (fracture group). Patients with multiple-level fractures, burst fractures and/or major trauma, such as that resulting from a traffic accident, were excluded from this study. We also reviewed MR images of 190 discs from 27 elderly patients diagnosed with lumbar stenosis, who had no previous history of vertebral body fractures (stenosis group).

RESULTS:

In the fracture group, 23% (17/74) of T1-weighted images exhibited a high-intensity area in the disc, whereas only 3% (5/190) exhibited a high-intensity area in the stenosis group. In some cases, in the T2-weighted images we also found a high-intensity zone in discs that showed low- or iso-intensity. This phenomenon was more frequently observed in the fracture group (47%: 35/74) than in the stenosis group.

CONCLUSION:

The present study indicates that, in elderly patients, intervertebral discs adjacent to vertebral fractures resulting from minor trauma are often injured. Because hemorrhage is the most likely cause of a high-intensity T1-weighted image, the results indicate that hemorrhage can be induced in a disc adjacent to a vertebral body fractured by even minor trauma.

 

 

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Spine J. 2006 Nov-Dec;6(6):624-35. Epub 2006 Oct 11.

 

Are first-time episodes of serious LBP associated with new MRI findings?

Carragee E, Alamin T, Cheng I, Franklin T, van den Haak E, Hurwitz E.

Source

Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Rm. R-171, Stanford, CA 94305, USA. This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Abstract

BACKGROUND:

Magnetic resonance (MR) imaging is frequently used to evaluate first-time episodes of serious low back pain (LBP). Common degenerative findings are often interpreted as recent developments and the probable anatomic cause of the new symptoms. To date no prospective study has established a baseline MR status of the lumbar spine in subjects without significant LBP problems and prospectively surveyed these subjects for acute changes shortly after new and serious LBP episodes. This method can identify new versus old MR findings possibly associated with the acute symptomatic episode.

PURPOSE:

To determine if new and serious episodes of LBP are associated with new and relevant findings on MRI.

STUDY DESIGN:

Prospective observational study with baseline and post-LBP MRI monitoring of 200 subjects over 5 years.

OUTCOME MEASURES:

Clinical outcomes: LBP intensity (visual analogue scale), Oswestry Disability Index, and work loss. MRI outcomes: disc degeneration, herniation, annular fissures, end plate changes, facet arthrosis, canal stenosis, spondylolisthesis, and root impingement.

METHODS:

200 subjects with a lifetime history of no significant LBP problems, and a high risk for new LBP episodes were studied at baseline with physical examination, plain radiographs, and MR imaging. Subjects were followed every 6 months for 5 years with a detailed telephone interview. Subjects with a new severe LBP episode (LBP>or=6/10,>1 week) were assessed for new diagnostic tests. New MR imaging, taken within 6 to 12 weeks of the start of a new LBP episode, was compared with baseline (asymptomatic) images. Two independent and blinded readers evaluated each baseline and follow-up study.

RESULTS:

During the 5-year observation period of 200 subjects, 51 (25%) subjects were evaluated with a lumbar MRI for clinically serious LBP episodes, and 3/51 (6%) had a primary radicular complaint. These 51 subjects had 67 MR scans. Of 51 subjects, 43 (84%) had either unchanged MR or showed regression of baseline changes. The most common progressive findings were disc signal loss (10%), progressive facet arthrosis (10%), or increased end plate changes (4%). Only two subjects, both with primary radicular complaints, had new findings of probable clinical significance (4%). Subjects having another MR were more likely to have had chronic pain at baseline (odds ratio [OR]=3.19; 95% confidence interval [CI] 1.61-6.32), to smoke (OR=5.81; 95% CI 1.99-16.45), have baseline psychological distress (OR 2.27; 95% CI 1.15-4.49), and have previous disputed compensation claims (OR=2.35; 95% CI 0.97-5.69). Subjects involved in current compensation claims were also more likely to have an MR scan to evaluate the LBP episode (risk ratio=4.75, p<.001), but were unlikely to have significant new findings. New findings were not more frequent in subjects with LBP episodes developing after minor trauma than when LBP developed spontaneously.

CONCLUSION:

Findings on MR imaging within 12 weeks of serious LBP inception are highly unlikely to represent any new structural change. Most new changes (loss of disc signal, facet arthrosis, and end plate signal changes) represent progressive age changes not associated with acute events. Primary radicular syndromes may have new root compression findings associated with root irritation.

 

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Br J Sports Med. 2007 Nov;41(11):836-41; discussion 841. Epub 2007 Jul 19.

 

MRI findings in the lumbar spines of asymptomatic, adolescent, elite tennis players.

Alyas F, Turner M, Connell D.

Source

Department of Radiology, Royal National Orthopaedic Hospital, Stanmore, London, UK.

Abstract

OBJECTIVE:

To describe magnetic resonance imaging (MRI) findings in the lumbar spine in asymptomatic elite adolescent tennis players, to serve as the baseline for a future prospective longitudinal cohort study.

DESIGN:

Observational study.

SETTING:

Institutional, national tennis centre.

PARTICIPANTS:

33 asymptomatic elite adolescent tennis players, mean (SD) age, 17.3 (1.7) years (18 male, 15 female).

METHODS:

Sagittal T1, T2, STIR, and axial T2 weighted MRI images were reviewed for the presence of abnormalities by two radiologists in consensus. Abnormalities included disc degeneration, disc herniation, pars lesions (fracture or stress reaction), and facet joint arthropathy.

RESULTS:

Five players (15.2%) had a normal MRI examination and 28 (84.8%) had an abnormal examination. Nine players showed pars lesions (10 lesions; one at two levels) predominately at the L5 level (9/10, L5; 1/10, L4). Three of the 10 lesions were complete fractures; two showed grade 1 and one grade 2 spondylolisthesis, both of which resulted in moderate narrowing of the L5 exit foramen. There were two acute and five chronic stress reactions of the pars. Twenty three patients showed signs of early facet arthropathy occurring at L5/S1 (15/29 joints) and L4/5 (12/29 joints). These were classified as mild degeneration (20/29) and moderate degeneration (9/29), with 20/29 showing sclerosis and 24/29 showing hypertrophy of the facet joint. Synovial cysts were identified in 14 of the 29 joints. Thirteen players showed disc desiccation and disc bulging (mild in 13; moderate in two) most often at L4/5 and L5/S1 levels (12 of 15 discs).

CONCLUSIONS:

Abnormalities were frequent, predominately in the lower lumbar spine, almost exclusively at L4/5 and L5/S1 levels. Pars injuries and facet joint arthroses were relatively common.

 

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References:

• http://emedicine.medscape.com/article/340014-overview
• http://www.premierradiologyservices.com/age_of_injury.asp
• Anatomical Diagrams - http://www.chirogeek.com/001_tutorial_birth_of_hnp.htm
• PubMed Search "acute disc herniation mri" showed 266 results