Please make one comment of things you see in this image. Comments can be of things that are normal or abnormal.
Sunday, April 9, 2017
65 year old with back pain
This image is from 65 year old with complaint of back pain after having week long cold with significant amount of coughing. Pain is general ache, but sharp with rotation and bending activities.
Please make one comment of things you see in this image. Comments can be of things that are normal or abnormal.
Please make one comment of things you see in this image. Comments can be of things that are normal or abnormal.
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In this image, you can see 5 vertebral bodies. Looking at the shape of the vertebral body in the center, it appears to demonstrate an anterior collapse. Our Musculoskeletal Imaging book would classify this as a wedge deformity that is often associated with compression fractures. While we don't know the patient's medical history, the American Academy of Orthopedic Surgeons states that "people with osteoporosis can suffer a fracture even when doing everyday things, such as reaching, twisting, coughing, and sneezing" (http://orthoinfo.aaos.org/topic.cfm?topic=A00538). Thus, it is possible that coughing could cause this kind of deformity in certain patient populations. The American Academy of Orthopedic Surgeons also state that vertebral compression fractures cause back pain that increases with motion and changing positions (http://orthoinfo.aaos.org/topic.cfm?topic=A00538). This also lines up with the symptoms that the patient is experiencing.
ReplyDeleteSara Ellis
I agree with Sara. The first thing I noticed in this radiograph was the wedge shape of the middle thoracic vertebra pictured. This wedge deformity of the anterior vertebral body is indicative of an anterior vertebral body compression fracture. Other radiographic signs of a compression fracture shown here include a loss of intervertebral disc height (which appears to be the case in the space above the compressed disc), and paraspinal edema (which is noted by increased radiodensity of the paraspinal musculature). This diagnosis is also consistent with the patient's age of 65, as compression fractures increase in incidence with age.
ReplyDeleteTaci Wilson:
ReplyDeleteI agree with the first two comments regarding possible compression fracture. This image shows a lateral view of the thoracic spine, you can tell that it is in the thoracic spine due to the ribs in the image. As noted in our text on pg 240 "anterior compression fractures compromise the majority of vertebral fractures in pts over 60 yrs of age". This image shows loss of anterior vertebral body height while the posterior body ,arches and ligaments appear to be intact, indicative of compression fracture pg 240 of our text. Common characteristics of compression fractures include: step defect, wedge deformity, impaction zone, displaced end plates, and loss of disc height. As Crystal stated the image shows loss of disc height. It is also evident that there is a linear line of impaction located with increased density between the body of the fractured vertebrae. However, I do not see much evidence of an anterior step defect which is common with this type of injury. Text: Fundamentals of Musculoskeletal Imaging by Lynn McKinnis.
Just at first glance, I noticed the faint diagonal white structures going across the vertebral bodies and recognized that those structures were the ribs. Therefore this image must be of the thoracic spine vertebrae. I also noticed that the middle vertebral body looks different than the others and agree with the previous comments that it presents similar to that of a thoracic spine compression fx.
ReplyDeleteAt first glance you can distinguish that the 3rd vertebral body down from the top of available image displays an anterior wedge shape deformity when compared to the other vertebrae. This visual information along with subjective reports and age of the Pt dealing with prolonged coughing and pain with bending and rotation would lead me to believe a anterior compression fx has occurred (likely in thoracic spine), in agreement with all the above comments. Pt may also have some form of degeneration/spondylosis and or arthritis of the spine by the increased sclerosis features of vertebral bodies and decreased disc space in various levels.
ReplyDeleteUpon reading the patient presentation, I automatically looked for rib dysfunction due to the patient's significant amount of coughing. With this radiographic view, rib dysfunction is hard to see. However, I did notice increased space between two of the middle ribs as compared to the others shown in the radiograph. This rib displacement could be caused by spasms of the intercostal musculature. Rib displacement could cause pain in the thoracic spine at the rib attachments. I was not able to see any rib fractures.
ReplyDeleteThis comment has been removed by the author.
ReplyDeleteThis image seems to be a lateral view of unknown vertebrae. This is likely a view of the thoracic spine due to the present of radiodense diagonal lines indicating undetermined ribs. There are 5 vertebrae visible with an obvious deformity of the third vertebra. The third, or middle vertebra seems to be wedged shaped due to an anterior compression of the vertebral body causing an increase in the intervertebral space above and below. In the space above the wedged shape vertebra, there seems to be an increase in radiolucancy indicative of edema or increased inflammatory factors.
DeleteI agree with the comments above. Given that 90% of anterior vertebral body fractures are due to flexion forces, a week of constant coughing in a 65 year old man could have caused this. When first looking at the imagine I believed the fracture to be in the lower thoracic spine due to the angle of the ribs. However, according to our book "the upper thoracic spine disks are thinner and less shock-absorbing, so forces are readily transmitted to the vertebral body", this would be especially true in the older population. "The collapse of the body thus results in a true wedge-shaped deformity." Therefore, I believe it is in the upper thoracic region. As far as stability is concerned the anterior column is compromised. I am unable to tell if the posterior ligament complex is damaged on this radio graph, and therefore do not know the condition of the posterior column. If it is only the anterior column that is jeopardized then the fracture would be considered stable. However if the posterior column is also damaged, the fracture then has the potential to be unstable.
ReplyDeleteGiven the age of the patient, the first thing I looked for was a fracture and then noticed the wedge deformity of the vertebrae due to an anterior compression fracture. I would classify this injury as a stable injury as it appears only one column is involved. The middle and posterior column seem to be uninjured.
ReplyDeleteJulia Zeiner
At first glance I recognized this was a view of the thoracic spine. Things to note in this image are the ribs, thoracic kyphosis, and a compression fracture, as indicated by the wedge shaped appearance of the 3rd vertebral body (from the top). The patient's symptoms match up with this image as compression fractures are common with increasing age. Additionally, there may be some degree of degenerative disc disease as indicated with varying amounts of disc space between adjacent bodies.
ReplyDeleteThis comment has been removed by the author.
ReplyDeleteI'm thinking this x-ray was taken through some venetian blinds, or those could be ribs and thoracic vertebrae. The middle vertebrae appears to have a compression fx. The others appear to have some bony over-growth, and possibly some endplate depression.
ReplyDeleteJames Holland
Located in thoracic spine, decreased disc height, anterior compression fracture of the vertebrae that is third from the top in the picture. Subjective information matches what we are observing through this radiograph. It is expected for the patient to have sharp pain when bending forward or rotating and it is also expected to have a general ache due to the fact that this patient has a anterior compression fracture.
ReplyDeleteCameron Moore
Reading all my other classmate's posts, I am in agreement that at initial look there appears to be an abnormality in the third vertebrae which appears to be within the thoracic spine. This deformity is wedged-shaped in appearance and there also appears to be black spot within the posterior longitudinal ligament (PLL) which could indicate a a tear. In our book, it states that a hyper-flexion injury can result in an anterior vertebral body compression fracture along with tear of the PLL. All of these objective findings coincide with the hyper-flexion MOI which is also in agreement with the patient's subjective statements as well as the patient's age.
ReplyDeleteSteph Shogren
This appears to be a lateral view of the thoracic spine as ribs are faintly seen in the image. The amount of kyphotic curvature would lead me to believe it is viewing the mid to upper T spine. The wedge shaped, possibly compressed vertebrae is most noticeable and would lead one to believe it was a result of the consistent coughing of the patient. An increase in internal pressure, forceful flexing cough, and kyphotic curvature were likely the main factors.
ReplyDeleteSpencer Shirk
Like everyone already said, this is clearly a radiograph of the thoracic vertebrae as evidenced by the presence of ribs. Since everyone also pointed out the wedge fracture of one of the vertebra, I'm going to take a stab at an alternative diagnosis. Tuberculosis osteomyelitis, also known as Pott's disease. It is always secondary to tuberculosis elsewhere in the body, which could explain the coughing. The early symptoms of bone tuberculosis is back pain. There is also a focal kyphosis and disc space may be spared, which it appears to be for the most part in this radiograph. Also, this condition is most common in the thoracic spine, which also fits this patient. Lastly, anterior to the vertebral bodies, which could be the lungs, there is a lot of radiodense material, which would also be consistent with TB. I don't know if I'm right, but it's a shot.
ReplyDeleteWhen first reading this subjective without really looking at the photo, I was expecting to find some sort of rib abnormality. However, as everyone as stated above an anterior vertebral body compression fracture does seem to be consistent by image and the limited subjective. It is interesting to note however that these vertebrae look to be vertebrae of the lower thoracic spine. Our book states that in the lower thoracic and lumbar spine, the intervertebral disks are thicker so they absorb shock better. So forces are more easily dispersed to the disk itself and the vertebral endplates. This results in a greater occurrence of associated endplate fractures and less of a vertebral body wedge deformity in this region.
ReplyDeleteAllie
Not that I can really comment on anything new, but I'll list off a few things. You can definitely see some degenerative changes- note the osteophytes hanging off the vertebral bodies. This looks like a lateral view to me, and like Jim said, either this has been taken through some kind of blinds or those are ribs. Hard to say, but the cloudiness anterior to the spinal column makes me wonder about some kind of fluid accumulation in the thoracic cavity... could be pneumonia.
ReplyDeleteAs my previous 17 classmates have already pointed out, this is a lateral view of the patient’s T spine as we can see those ribs (or Venetian blinds). I also noticed the obvious wedge deformity of the 3rd vertebral body from the top, however I see a difference in disc height between the 4 discs visible. There is what appears to be Schmorl’s nodes present on the inferior side of the 2nd vertebra as well as on both sides of the 3rd vertebra. Additionally, some osteophyte formation is visible on the vertebral margins of the 2nd, 3rd, and 4th vertebral bodies. Finally, we can see the end plates of the vertebral bodies appear bright white (which is a normal finding).
ReplyDeleteThe 3rd vertebral body (in the image) is shorter anteriorly than posteriorly indicative of a anterior compression fracture that is commonly associated with Pt's with osteoporosis. These fractures can occur without major trauma and causes moderate to severe pain that is worsened with movement. There are also degenerative changes consistent with the Pt's age such as osteophyte formation and decreased disk space height. I'm so glad Jameson said it first but I was thinking he has PNEUMONIA (seeing the lung field abnormally white) because studying for the Board exam there was a question that I had to teach myself before this class concerning a Pt with pneumonia whether his chest x-ray would be radiolucent or radiopaque! I know that's not our concern as musculoskeletal specialists but I like to know things! I'd tell the guy to get better and stop coughing cause its making his pain worse!
ReplyDeleteAndrea Dimmen
Looks like this is a Lateral view of our patients lateral spine. Noticing the ribs running lateral and inferior. Looks to me as everyone has stated already an anterior compression fracture at the 3rd vertebrae from the top. You also notice the wedge shape, and a slight linear zone of impaction with increased density beneath the endplate. Since the patient states she has been coughing and the radiograph is slightly cloudy I have a thought as Jameson stated there could be Pneumonia. I also notice normal osteophytic changes at posterior vertebral body which fits her age range. Looking at the bottom segment this looks as if we are going in lower thoracic into thoracolumbar section due to the widen thicker vertebral body.
ReplyDeleteKorey Ramsey
in this image i see that it is a lateral view. It looks as though it is of the thoracic spine due to the ribs. When examining the vertebral bodies they seem to have a little bit of spondylosis going on with the appearance of degeneration of the bodies which makes sense with the patients age. They seem to have a bit more density at either end leading me to believe there is an increase in osteophytes. Pain with coughing could be due to the increased osteophytic changes causing a pinching with the increase in pressure and narrowed joint space. The superior portion of the 3rd vertebral body has a dip towards the middle, this may be due to a compression fracture anteriorly or a defect in the endplate causing it to be degenerated more towards the middle.
ReplyDeleteMandy Spencer
Out of the vertebrae you can see completely, the second one from the bottom has a compression fracture. You can see a horizontal line going through the body, which is the fracture line. The height of the vertebrae is also an indicator of this, as it looks “shorter” than its neighbors. As we’ve learned in classes, axial loading is the main MOI for these, and osteoporosis is the main predisposing factor. That makes me wonder if this is a woman with osteoporosis who suffered this fracture as a result of the coughing she was experiencing.
ReplyDeleteThis appears to be a lateral view of the spine, likely the thoracic spine judging by the presence of ribs in the image. It is easy to see that one of the vertebra in the middle has decreased height, indicating a probable compression fracture of the thoracic vertebra. The patient's age and presentation would contribute to the likelihood of this diagnosis. The fact that the patient has been coughing significantly recently could have been the MOI. There also appears to be a decrease in space between the two vertebra at the top of the image, possibly indicating degenerative disc disease, which again would fit the patient's age and presentation.
ReplyDeleteKatie Klausmeyer
With this lateral view of the thoracic spine and appearance of ribs, it is easy to see 5 vertebral bodies. With regards to the middle thoracic vertebrae in this image, I notice some discrepancies in the shape and possibly a wedge deformity. This image also demonstrates a loss of vertebral body height, which is consistent with a compression fracture. Our book, Fundamentals of Musculoskeletal Imaging by Lynn Mckinnis, states that at least 30% loss of the vertebral body height is required for the wedge deformity to be present on the radiograph. Given the patient's age, gender, and presentation, it may be assumed that this patient may have suffered a compression fracture in her thoracic spine. A common causes of compression fractures includes osteoporosis. University of Maryland Medical Center states that about 40% of all women will suffer from at least one compression fracture before the age of 80. In severe cases of osteoporosis, actions such as bending forward can be enough to cause a “crush fracture.”
ReplyDeletehttp://www.umm.edu/programs/spine/health/guides/thoracic-compression-fractures
Taylor Sisneros
The first thing that I notice about the picture is the diagonal sloping of the ribs, which to me indicates that it is either a lateral or anterior oblique view. When looking at this image these two views are difficult to differentiate between because the image is very close and it is difficult to visualize the spinous processes. Upon further inspection, the most concerning aspect is the decreased height of the 3rd vertebral body from the top. This decreased height is indicative of a vertebral compression fracture. This could be the cause of the patient’s pain with rotation and bending. I am curious to know if the compression fracture could have been caused from the pressure of coughing with the patient’s recent illness. This would be possible in someone with decreased bone density, which would be likely in someone that is 65 years old, particularly if they were a Caucasian female.
ReplyDeleteSarah Woodruff
This appears to be a lateral view of the thoracic spine, as you can see ribs. The middle vertebrae appears to have a wedge deformity by the trapezoidal shape of the vertebral body. It looks like this patient may have a compression fracture which could have been caused by all of the coughing that they have been doing, creating a flexion force which causes 90% of anterior vertebral body compression fractures. Another factor is the age of the patient since osteoporosis can decrease the force required to result in a compression fracture.
ReplyDeleteClaire Cox
I also have to agree with my classmates. The first thing I noticed, was that this image was assessing the spine. To orient myself to the specific location, the ribs helped me to realize that I was looking at the thoracic spine. Then the next thing I tried to do was assess the alignment, even though I don't think this is a lateral view I tried to draw the anterior and posterior vertebral body lines. There seems to be a little bit of a step-off between the 4th and 3rd vertebrae in the picture, but overall the alignment didn't seem too terrible. I then noticed that the third vertebral body (from the top) demonstrates some structural deformities, especially when compared to the other vertebral bodies. It displays a wedge-shaped appearance which made me think anterior compression fracture. Given that our patient is over 65 (post-menopausal) she could have either osteopenia or osteoporosis which would put her more at risk for compression fractures, and as the books states in these cases, compression fractures may result from "minimal imposed forces" (persistent cough). Also, further evidence of anterior compression fractures includes the decreased disc space between the 2nd and 3rd vertebrae pictured and the objective findings of pain with bending and rotation.
ReplyDelete-Megan Wiederholt
Presence of diagonal lines indicate that this is an image of the thoracic spine. 5 thoracic vertebrae are noticeable in the image. The 3rd vertebrae from the top has a wedge shape on the anterior side, which is consistent with a compression fracture. Taking into the account the patients age and the fact that he has had a cough for a week, it is highly likely that coughing was his mechanism of action with weak bone integrity.
ReplyDeleteMatt Dobratz
Presence of diagonal lines indicate that this is an image of the thoracic spine. 5 thoracic vertebrae are noticeable in the image. The 3rd vertebrae from the top has a wedge shape on the anterior side, which is consistent with a compression fracture. Taking into the account the patients age and the fact that he has had a cough for a week, it is highly likely that coughing was his mechanism of action with weak bone integrity.
ReplyDeleteMatt Dobratz
I agree with my classmates that this is a lateral/oblique view of the thoracic spine. There is what appears to be a compression fracture of the middle vertebrae as well as some osteophyte formation around the posterior aspect of the vertebral bodies. Another thing is that the 2nd vertebrae from the top appears to have an uneven inferior surface, it is pushed up in the middle. This may be due to swelling or a disk protrusion up into the endplate.
ReplyDeleteAshley Johnson
I agree with my fellow class mates this is a lateral view of the thoracic spine indication compression fracture with a wedge shaped deformity. It also appears that there could be some decreased disk height indication Degenerative disc disease. I also notice that there is no sign of a spondylolistheis. As someone who has one this is something I look for right off the bat.
ReplyDeleteI can see the presence of the wedge deformity by noticing the trapezoidal shape of the vertebral body. This patient could have a IV disk herniation due to the compression fracture leading to the pain when he is coughing, twisting or bending as the collapse of a vertebral body increases the change of a herniation.
ReplyDeleteBROOKE HANSEN
DeleteIt is a lateral oblique view of the thoracic spine due to seeing the ribs int he picture. A compression fx of the middle thoracic vertebra with a wedge deformity. There is more of a kyphotic positioning of the spine so I believe this would be more middle thoracic.
ReplyDeleteJULEE MCMULLEN
DeleteThis is a lateral view of the thoracic spine. This view is beneficial because it allows you to visualize the vertebral bodies, pedicles, laminae, intervertebral foramina, axillary portion of the ribs and the diaphragm. Since the diaphragm is visible in this radiograph, one could assume that this is not a swimmer's lateral projection. A swimmer's lateral projection is used to visualize the upper thoracic spine and is done so by positioning the arm overhead to remove the obstruction of the shoulder. This lateral view is beneficial because it provides the best visualization of the vertebral body in the saggital plane and allows you to visualize the 3 columns; anterior, middle and posterior. In this specific radiograph there is a good visualization of the anterior and middle columns. Looking at this radiograph, you can see there is a anterior vertebral body compression fracture, only consisting of the single anterior column. We know this is a recent fracture by visualizing 3 signs in the radiograph; step defect, wedge deformity and the linear zone of impaction being the linear band of increased density that is apparent beneath the involved end plate. These 3 signs tell us that this fracture is less than 2 months old. Based on this patient's age and sex, one would begin to assume that this fracture could be a result of osteoporosis. However, more testing would be needed to give this diagnosis of this patient.
DeleteBrent Davis
I agree with my class mates that the most obvious abnormality in this image is the wedge deformity indicating a wedge fracture. Another thing of note is the large amount of white (radiodense material) in this image. This could indicate fluid buildup in the lungs lending to pt's cough and thoracic vertebral fracture.
ReplyDelete-James Quinn
I as well agree with all my classmates. The image dictates a wedge deformity of the middle vertebrae shown on a lateral view indicating an anterior vertebral compressional fracture. As stated in the book the compression fractures are most common in ages over 60. Our patient is 65 which makes him more susceptible to this type of fracture possibly due to osteoporosis as well as the thickness of the disc and loss of height decreasing with age. Also his coughing could of been a precursor (MOI) to the fracture above.
ReplyDeleteMelissa
My attention is first captured by the extreme amount of radiodense (white portion of the imaging) which could indicate accumulation of fluid or pneumonia with patient. I along with my class agree and would volunteer that the abnormal findings of this image would be a wedge deformity, which also fits the patient's age range.
ReplyDeleteL. Williams
Great comments. You are right that this is a case of compression fracture and some degenerative disk disease. However - excellent points that you all made regarding potential of rib dysfunction, pneumonia and of other pathology.
ReplyDelete