The spine in health and disease by BIR Publishing

21 JANUARY 2015

THE SPINE IN HEALTH AND DISEASE Venue: British Dental Association, London CPD: 6 CREDITS

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BIR ANNUAL CONGRESS 2015 4–5 NOVEMBER LONDON • Room 1

Primers for the non-specialists

Day 1

Session organised by Dr David Wilson, Consultant Interventional MSK radiologist, Oxford University Hospitals NHS Trust

Day 2 Clinical hybrid imaging in oncology • Room 1

Session organised by Dr Gopinath Gnanasegaran, Consultant Physician in Nuclear Medicine, St Thomas’ Hospital

• Room 2

Session organised by Mr Andy Rogers, Head of Radiation Physics, Nottingham University Hospitals NHS Trust

Session organiser to be confirmed

Radiation protection

More information available soon at www.bir.org.uk

Trauma imaging Essentials for the radiology trainee Session organised by Dr Hardi Madani, Radiology Registrar, Royal Free London Hospital, and Dr Ausami Abbas, Cardiothoracic Radiology Post CCT Fellow, University Hospital Alberta

Welcome and thank you for coming to ‘The spine in health and disease’ organised by the British Institute of Radiology. We wish you a very enjoyable and educational experience. Certificate of attendance This meeting has been awarded 6 RCR category I CPD credits. Your certificate of attendance will be emailed to you within the next two weeks once you have completed the online event survey at: https://www.surveymonkey.com/s/TheSpine

BIR Annual Congress 2015: 4–5 November, London

We are most grateful to

for supporting this conference.

Programme

09:00 Registration and refreshments 09:25 Welcome and introduction Dr Tuhin Sikdar, Consultant Radiologist, Princess Alexandra Hospital 09:30 Anatomical considerations in the spine Dr Dimitri Amiras, Consultant Radiologist, Imperial College Hospitals 09:50 Embryology and development of the osseous spine Professor Filip Vanhoenacker, Consultant Radiologist, University Antwerp, Belgium 10:10 Spinal infections Dr Thillainayagam Muthukumar, Consultant Musculoskeletal Radiologist, Royal National Orthopaedic Hospital

10:30 Tumour-like conditions of the spine Dr Asif Saifuddin, Consultant Musculoskeletal Radiologist, Royal National Orthopaedic Hospital 11:00 Refreshments 11:20 Degenerative disorders Dr Thillainayagam Muthukumar, Consultant Musculoskeletal Radiologist, Royal National Orthopaedic Hospital

11:45 Seronegative spondyloarthropathies Dr Marianna Thomas, Consultant Radiologist, Royal United Hospital 12:15 DISH, OPLL and other ossific/calcific conditions in the spine Professor Filip Vanhoenacker, Consultant Radiologist, University Antwerp, Belgium 12:40 Discussion 12:50 Lunch 13:30 Spinal tumours Dr Asif Saifuddin, Consultant Musculoskeletal Radiologist, Royal National Orthopaedic Hospital 14:00 Vertebroplasty: where are we now? Dr Damien Taylor, Consultant Radiologist, Hull and East Yorkshire Hospitals 14:30 Cervical spine trauma Dr Prudencia Tyrrell, Consultant Radiologist, Robert Jones and Agnes Hunt Hospital 2

15:00 Refreshments 15:20 Thoracolumbar spine trauma Dr Tuhin Sikdar, Consultant Radiologist, Princess Alexandra Hospital 15:40 Spinal intervention: how I do it Dr Damien Taylor, Consultant Radiologist, Hull and East Yorkshire Hospitals 16:10 The post-operative spine Dr Prudencia Tyrrell, Consultant Radiologist, Robert Jones and Agnes Hunt Hospital 16:40 Questions and discussion 16:45 Close of event _______________________________________________________________________

Certificate of attendance This meeting has been awarded 6 RCR category I CPD credits. Your certificate of attendance will be emailed to you within the next two weeks once you have completed the online event survey at: https://www.surveymonkey.com/s/TheSpine BIR Annual Congress 2015: 4â&#x20AC;&#x201C;5 November, London

Speaker profiles Dr Dimitri Amiras Consultant Radiologist, Imperial College Hospitals Dr Amiras completed radiology training at Charing Cross and Hammersmith Hospital with subspecialisation in musculoskeletal radiology. After completing his radiology training and initial subspecialisation he furthered his training with fellowships in Fremantle Hospital, Western Australia and observerships at the Academic Medical Centre in Amsterdam and Auckland City hospital in New Zealand. Dr Amiras is a keen sportsman with international rugby cap and an AIDA qualified free-diver. Dr Thillainayagam Muthukumar Consultant Musculoskeletal Radiologist, Royal National Orthopaedic Hospital Dr Muthukumar qualified from India in medicine with a post-graduate degree in radiology from Nagpur University. Subsequently, he underwent 2 years training at the Christian Medical College Hospital at Vellore. He joined the radiology training scheme at the Aberdeen Royal Infirmary followed by a fellowship in musculoskeletal radiology at the Robert Jones and Agnes Hunt Orthopaedic Hospital at Oswestry. He joined as Consultant Musculoskeletal Radiologist at the Royal National Orthopaedic Hospital in 2005. His active interests are in interventional musculoskeletal radiology, complex spine and sarcoma. He deals with sports injuries of international footballers and cricketers. He is also an honorary visiting professor to the Tamil Nadu Dr MGR Medical University in Chennai. Dr Asif Saifuddin Consultant Musculoskeletal Radiologist, Royal National Orthopaedic Hospital Dr Asif Saifuddin is the senior Musculoskeletal Radiology Consultant at the Royal National Orthopaedic Hospital NHS Trust, where he has been in post since 1994. His major interests are in musculoskeletal tumour imaging and spinal imaging. He has authored over 200 papers, several book chapters and also the textbook Musculoskeletal MRI, published in 2008. Dr Tuhin Sikdar Consultant Radiologist, Princess Alexandra Hospital Dr Tuhin Sikdar is Consultant Radiologist at Princess Alexandra Hospital, Harlow, Essex. He has special interests in musculoskeletal radiology and non-vascular intervention. He is Clinical Tutor for the East of England Deanery and committed to 4

postgraduate education in radiology. His surgical training was in the Newcastle-upon-Tyne group of hospitals and he obtained the FRCS in 1989. His training in Radiology was at the Charing Cross and Hammersmith Hospitals, now part of the Imperial College Healthcare NHS Trust London, and later at Royal National Orthopaedic Hospital in Stanmore. He has developed a keen interest in musculoskeletal intervention and MR and has conducted and contributed to spinal intervention workshops internationally. He is an enthusiastic medical educator regularly contributing to revision courses for radiology and orthopaedic trainees and organising educational meetings for the British Institute of Radiology where he was conferred Honorary Fellowship in 2012. Dr Damien Taylor Consultant Radiologist, Hull and East Yorkshire Hospitals Dr Taylor trained in Bristol and worked as a Senior Registrar at Charring Cross Hospital in the early 1980â&#x20AC;&#x2122;s. He has been a Consultant Radiologist in Hull since 1987 which is now part of the Hull/York Medical School. He is an active member of the BSSR. He is Clinical Lead in MSK imaging for his Trust. He has pioneered vertebroplasty and has lectured on the subject extensively. He also has a major interest in all forms of spinal intervention, inlcuding biopsy and pain relief procedures. He hopes to share his experiences with you and introduce you to some new techniques. The spinal intervention lecture will be dedicated to Dr Bill Parks. Dr Marianna Thomas Consultant Radiologist, Royal United Hospital Marianna Thomas is a Consultant Radiologist at the Royal United Hospital Bath Foundation Trust, including the Royal National Hospital for Rheumatic Disease. Having qualified from University College London medical school and completed subsequent postgraduate training, she went onto specialty Radiology training in the East Midlands Deanery. She undertook a fellowship in Musculoskeletal Radiology at Norfolk and Norwich University Hospital prior to starting in her current post in 2013. Dr Prudencia Tyrrell Consultant Radiologist, Robert Jones and Agnes Hunt Hospital Dr Prudencia Tyrrell is a Consultant Musculoskeletal Radiologist at the Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, a specialist tertiary referral orthopaedic hospital. She was apponted in 1995. Her special interests include the spine and also bone and soft tissue tumours. 5

Professor Filip Vanhoenacker Consultant Radiologist, University Antwerp, Belgium Professor Filip Vanhoenacker became a Specialist in Radiology in 1991 and is now a Consultant Radiologist and Lecturer at University Antwerp and a Guest Professor at the University of Ghent. He has been the co-author and co-editor of numerous books, including ‘Medical Imaging of the Spleen’ and ‘Imaging of Soft Tissue Tumors’. He was also the main editor for the book ‘Imaging of Orthopedic Sports Injuries’. He is a member of many different radiological societies, including American Roentgen Ray Society, ECR, Royal Belgian Soiety of Radiology, European Society of Musculoskeletal Radiology (ESSR), ISS, Ameriacan Society of Spine Radiology, and a corresponding member of RSNA. In addition, he has acted as the Secretary and President of the Osteo-articular section of the Royal Belgian Society of Radiology, and Counsellor and Educational Committee Chairman of the ESSR.

Abstracts Anatomical considerations in the spine Dr Dimitri Amiras The spinal anatomy represents millions of years of evolution from invertebrates to vertebrates to bipedal hominids. This lecture intends to give a gentle review of the osteology, discal, muscular, ligamentous and neural anatomy with some reference to your vertebrate colleagues and some clinical examples. There will be a specific focus on discal anatomy and corresponding anatomy of the nervous system and terminology. Embryology and development of the osseous spine Professor Filip Vanhoenacker The development of the vertebral column comprises of three major stages, the precartilaginous stage, the cartilaginous stage and finally the bony stage. The precartilaginous stage or mesenchymal stage starts at week four of foetal life with sclerotome formation followed by resegmentation of sclerotomes. The cartilaginous stage (chondrification) begins at week six of foetal life. The bony stage (ossification) starts during the embryonic period and is completed by the age of 25. At the end of the embryonic period, 3 primary ossifications centers appear, i.e. in the centrum and in each half of the vertebral arch. At birth, each vertebra consists of three osseous parts connected by cartilage. The vertebral arch halves fuses at 3-5 year of age. Fusion of the posterior elements occurs first at the lumbar region and spreads then cranially. At puberty, five secondary ossification centers are present, i.e. two rim epiphyses at the superior and inferior vertebral body respectively, at tip of each transverse process and one at the tip of spinous process. Fusion of these secondary ossification centers is completed at the age of 25. Errors in formation, resegmentation, chondrification and ossification may result in morphological anomalies of the vertebral column. During the fetal period, the normal curve of the vertebral column is kyphotic. During infancy, cervical lordosis develops as the child is holding its head upright, whereas lumbar lordosis develops secondarily due to sitting and standing posture. In 95% of the population seven cervical vertebrae, twelve thoracic vertebrae, five lumbar vertebrae and five sacral vertebra are present. In 3% of the population, one or two additional vertebrae are seen, whereas 2% have less. 7

Learning objectives: • To summarise the different stages in development of the osseous spine • To illustrate how errors of these embryologic steps may result in congenital abnormalities and variants References: • Kaplan KM, Spivak JM, Bendo JA (2005). Embryology of the spine and associated congenital abnormalities. Spine J. 5(5):564-76. • Schoenwolf GC, et al. (2009). Larsen’s Human Embryology, 4th Edition, Churchill Livingstone, Elsevier. • http://web.indstate.edu/thcme/duong/EMBRYOL.html#anchor59130 Spinal infections Dr Thillainayagam Muthukumar The pathoanatomic processes in spinal infection will be reviewed. The different imaging appearances will be demonstrated. Radiological management of suspected spinal infection will be discussed. Tumour-like conditions of the spine Dr Asif Saifuddin For the purposes of this presentation, non-neoplastic lesions (NNL) of the vertebral body include all those focal lesions that may be identified on spinal imaging that can mimic benign or malignant vertebral tumours, excluding acute spinal trauma. Such lesions may be present with spinal pain but rarely with any associated neurological deficit, or they may be identified incidentally. They can also be solitary, and therefore be mistaken for primary tumours, or multifocal and be mistaken for metastatic disease. However, the majority have classical imaging features on a combination of radiography, MRI and CT that can allow a confident diagnosis without the requirement for needle biopsy. Such lesions may represent normal variants or be degenerative, traumatic, infectious, inflammatory or metabolic in nature. Normal variants of marrow include focal marrow hyperplasia and the giant notochordal rest. Degenerative lesions include discogenic hemivertebral sclerosis and the rare variants of Schmorl’s nodes. Traumatic causes include benign osteoporotic collapse, which must be differentiated from pathological collapse. Infections mimicking tumour include cases of osteomyelitis without disc involvement, most commonly TB which can be multifocal simulating metastases. Inflammatory lesions include the various causes of spondyloarthropathy, such as ankylosing spondylitis, SAPHO syndrome and CRMO, the latter two conditions being characterised by the combination of osteitis and hyperostosis, while metabolic conditions include Paget’s disease. In cases where the diagnosis cannot be made on MRI alone, CT is often very helpful.

Educational aims: • To illustrate the imaging features of the more common non-neoplastic vertebral lesions, so that accurate diagnosis based purely on imaging can preclude the requirement for needle biopsy Degenerative disorders Dr Thillainayagam Muthukumar This talk will describe the pathoanatomic processes occurring in spinal degenerative disease. Imaging modalities used in evaluation of degenerative processes will be discussed. Seronegative spondyloarthropathies Dr Marianna Thomas Spine imaging is performed as part of the initial assessment for clinically suspected axial spondyloarthropathy, although it does not count towards the widely used ASAS diagnostic criteria. The imaging arm of these criteria require the presence of radiographic sacroiliitis according to the modified New York criteria or evidence of sacroiliac joint inflammation on MRI, in addition to the typical clinical features. Radiographic and MRI findings in the spine and sacroiliac joints are presented, and the utility of these findings for the diagnosis of spondyloarthropathy discussed. In addition, examples of differential diagnoses are shown. The role of imaging in further management of the seronegative spondyloarthropathies, complications of the condition and some technical aspects of imaging will also be described. Educational Aims: • To understand the role of imaging in the diagnosis and management of seronegative spondyloarthropathies • To recognise the imaging features of the disease and its complications • To gain knowledge of standard MRI protocols of the spine and sacroiliac joints Learning objectives: • To identify features of seronegative spondyloarthropathy on radiographs and MRI of the spine and sacroiliac joints, and provide an assessment of the probability of the diagnosis • To distinguish imaging features of axial spondyloarthropathy from the common differential diagnosis

DISH, OPLL and other ossific/calcific conditions in the spine Professor Filip Vanhoenacker DISH, spondylosis and osteochondrosis of the spine are common incidental findings on imaging, often seen in middle-aged and elderly patients. CPPD and HADD (pseudogout) about the spine are also relatively common, but are rarely symptomatic (e.g. crowned dens syndrome and calcification of the m. longus colli). OPPL typically affects the cervical spine and is more common in Asian people than in Europe. Syndesmophytes are the hallmark of longstanding inflammatory disease of the spine. SAPHO typically affects the spine and the sternoclavicular joints. Other metabolic disorders associated with calcifications or ossifications in the spine are fluorosis, acromegaly, haemochromatosis, hypoparathyroidism, ochronosis, hypophosphatemic osteomalacia and rarely Paget’s disease. Any cause of spinal ankylosis may predispose to unstable spinal fractures, which are often difficult to assess on conventional radiographs. Even minor trauma may cause severe neurological deficit in those patients. Although CT is excellent to evaluate the extent of the fracture, MRI is often needed to evaluate the spinal cord. Learning objectives: • To discuss the differential diagnosis of calcifications and ossifications in the spine • To discuss the clinical significance of these imaging findings Spinal tumours Dr Asif Saifuddin Vertebral tumours can be either benign or malignant, the latter being either primary or more commonly metastatic. They commonly produce spinal pain with or without neurological deficit, and have a wide age of presentation. Vertebral haemangioma is the commonest benign tumour, typically found incidentally on spinal MRI, and the vast majority are easily characterised due to their fatty SI. Other primary benign tumours usually present in children and are a common cause of painful scoliosis, which can be reactive or structural. Osteoid osteoma and osteoblastoma present with reactive scoliosis and paraspinal tenderness, the lesion typically located in the neural arch on the concave side at the apex of the curve. Spinal aneurysmal bone cysts can preferentially involve one side of the vertebral body resulting in asymmetrical collapse and a structural curve, the lesion commonly containing multiple fluid levels. The majority of benign vertebral tumours are adequately characterised by imaging and do not require

diagnostic needle biopsy. Malignant tumours typically affect the vertebral body and may produce pathological collapse with the potential for cord compression, usually in adults. The commonest lesions are metastases, plasmacytoma/myeloma and lymphoma and they have few characterising features. Therefore, a patient presenting with single level pathological marrow infiltration, with/without collapse will likely require diagnostic needle biopsy. Educational aims: • To illustrate the imaging features of the commoner benign and malignant vertebral tumours • To indicate which can be confidently diagnosed by imaging alone without the requirement for needle biopsy Vertebroplasty: where are we now? Dr Damien Taylor This presentation will provide an overview of the patho physiology of spinal fractures and the role of vertebroplasty, kyphoplasty and sacroplasty in modern practice. Cervical spine trauma Dr Prudencia Tyrrell Injury to the cervical spine accounts for approximately 33% of all spinal injuries but the risk of neurological damage in the cervical region is significantly higher than in other areas of the spine. Cervical cord injury has devastating consequences for the patient and their family. Despite the advances in imaging, the initial clinical assessment – history and examination – remains paramount in directing the further imaging course. The scope of this talk will cover missed injuries and why they still happen. The role of radiographs and cross-sectional imaging is discussed, together with a number of case based scenarios illustrating the value and additional information that can be provided. Despite computed tomography (CT) having become the initial imaging modality of choice in the acute high impact injury, plain radiographs are still employed and knowledge of the approach to interpretation remains important. Some clinical situations where interpretation may be difficult require special mention including the elderly, the adolescent and the patient with a rigid spine. This will be discussed in more detail.

Thoracolumbar spine trauma Dr Tuhin Sikdar The incidence of spinal trauma continues to rise with resultant increase in the cost of healthcare provision for treatment and rehabilitation. Recognition of the injury pattern is crucial in achieving a more comprehensive understanding and assessment of thoracolumbar spinal injury. Many classification systems exist and range from too simplistic to overly complex. The Denis classification is one that is widely used and is based on plain radiographic appearances. There are however distinct patterns of injury that exist and recognition of this pattern helps in prediction of the full extent of injury. The role of imaging will be discussed in this presentation. Conventional radiography remains the initial screening method in most centres. With increasing use of spiral CT, there is less reliance on plain radiographs in assessment of the polytrauma patient. Multidetector row CT helps in assessment of thoracic and abdominal organs besides providing spinal evaluation. The high resolution of CT with ability to multiplanar reconstruction gives a better understanding of these injuries, helps assess spinal stability and guide patient management.MR remains the imaging modality of choice for direct imaging of the spinal cord and is best placed to assess the extent of soft tissue injury. It provides information on the nature and extent of spinal canal compromise, helps ensure rational approach to the surgical management of fracture and may be used to predict outcome. Spinal intervention: how I do it Dr Damien Taylor This presentation will provide an overview of spinal intervention techniques, with particular emphasis on vertebral biopsy for infection. There will also be a discussion of less common practical pain relief procedures. The post-operative spine Dr Prudencia Tyrrell Spinal surgery is most frequently performed to decompress (disc herniation, stenosis, malignant infiltration), to fuse and stabilise (particularly following trauma or infiltrative destructive processes) and to correct deformity. Often there may be a combination of these procedures at one operation. Surgical instrumentation or bone graft are sometimes employed. Patients presenting with symptoms post operatively may be early or late relative to the procedure and in turn symptoms may relate to the surgical procedure itself or be completely unrelated to the surgery. A number of post-operative complications are discussed and images shown to try and illustrate both the normal and abnormal post-operative findings in the spine. 12

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