1 Zainab Humaid Said Al - GhafriCourse Name :Medical Imaging CP (2) Course Instructor :Mohamed Mahmoud Abu Zaid Course Number : Zainab Humaid Said Al - Ghafri

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3 Objectives : Introduction Anatomy of the lumbar spineRadiographic anatomy Pathology & Treatment related to the low back pain Symptoms Diagnosis and examination Clinical Assessment and investigation requested Medical Diagnostic Imaging Brief description of MDI procedure Results of MDI Description of physician's diagnosis A comparison of MDI & Physicians diagnosis Patient outcome Patient prognosis Discussion of effectiveness of MDI investigation Conclusion References

4 Introduction: Patient Presented

5 Anatomy Of the Lumbar Spine:

6 The Vertebral Numbering:The cervical vertebra are referred to as C1-C7. The thoracic vertebra are referred to as T1-T12. The lumbar vertebra are referred to as L1-L5. The sacrum and coccyx consist of fused vertebra. The sacrum consists of 5 fused vertebra, and the coccyx consists of 3-5 fused vertebra. In between each vertebra you have an intervertebral disc, which forms a cartilaginous joint between the vertebra.

7 The Lumbar spine consists of:1)Vertebrae it is irregular bony structures linked together by ligaments and separated from each other by cartilaginous joints called discs in which they form that flexible curved column. The vertebra itself consists of: Body or Centrum Pedicles: Laminae: Spinous process: Transverse processes: Facet Joints:.

8 2) InterVertebral Discs:spongy compressible flexible fibrocartilage circular in shape flat pads high water content of about 90%

9 Disc/intervertebral Disc Function :These discs work as a divider between each vertebrae,they function to absorb shock and to allow slight movement between the vertebrae. The intervertebral disc is composed of two parts: the central portion with a gelatin-like consistency named "nucleus pulposus" and a fibrous fold to hold it tightly in place, called "annulus fibrosis" or " fibrous ring". The fibrous ring is thicker at the anterior portion of the disc; the posterior portion is more fragile. This is why, in case of disc herniation, this occurs mostly on the posterior part of the disc, causing disc herniation

10 3) Ligamentum Flavum: It is dense connective tissue that connect bones to bones at joints. It is the strongest of the spinal ligaments. It is called flavum to describe the color of it which is yellow. It protect the neural elements and the spinal cord. stabilize the spine so that excessive motion between the vertebral bodies does not occur. Together with the laminae, it forms the posterior wall of the spinal canal. Help to preserve the normal curvature of the vertebral column and to straighten the column after it has been flexed.

11 Spinal Cord It is the central portion of the nervous system of human.It is a vital passage that transmits signals from the brain to the rest of the body through individual nerve fibers. It is about 42 cm long and it is enclosed inside the vertebral column. It starts from foramen magnum of the skull and end at level of first or second lumbar spine.

12 Spinal Canal It is a cavity made by the bones of the vertebrae and the ligaments in which spinal cord pass through. It provides protection and nutrition for the spinal cord.

13 Radiographic anatomy

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15 Pathology: L5/S1 disc (Herniated disc): it is known also as “slipped,””ruptured, “or “torn” disc. It occurs whenever posterior longitudinal ligaments of the vertebra are injured or weekend. In that case the pressure on the “nucleus pulposus” the central portion of the disc might be great enough to cause rupture in “annulus fibrosus” which is surrounding the nucleus of the disc. If this happened the central part of the disc “nuclus pulposus” may protrude backward touching spinal cord and spinal nerves resulting in acute back pain and it may radiate to the lower body parts.

16 Symptoms: Person may complain of :sharp cutting pain-localized low back pain. This may radiate to the lower body parts causing: leg ache numbness

17 Examination to confirm diagnosis:Neurological examination performed by a doctor An EMG or electromyographic test Anterior posterior (AP), lateral and coned view projection films using x-rays. CT scan of lumbar region Magnetic resonance imaging(MRI) of lumbar region

18 Treatment: Treatment options include:Bed rest; short period of bed rest followed by a gradual return to normal activities Medication for pain; this include anti-inflammatory drugs, analgesics and muscle relaxants or tranquilizers. For my case patient was given Muscadol tablets and muscular relaxant ointment. Physiotherapy: sessions conducted by doctor according to the condition.

19 Exercise: Included low impact aerobic exercise like swimming, cycling, walking. Spine stabilization and strength training “exercise called lumbar extension strength training”. Flexibility exercise :may help in reducing pain

20 Surgical treatment: Done if period of time passed and the conservative treatment failed to make patient’s condition better. For example: Discectomy (complete disc removal) Micro discectomy ( partial disc removal).

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22 Clinical Assessment: A 55 years old female patien presented with progressive left sided leg pain and numbness which started two years ago The range of leg movement was resticted. Clinical assessment &diagnosis by physician for current investigation: Acute low back pain with left lower part sciatica. To rule out L5-S1 prolapsed disc. Investigation requested: Patient was scheduled for MRI Lumbar spine. Urea and creitenin test.

23 Medical diagnostic imagingBrief description of MDI examination: Patient was called by technologist and her ID was checked MRI Screening form was explained to patient and consent obtained she was told to change in to MRI gown as she was wearing local dress with metallic buttons.  She was told to empty the bladder as the exams takes time. The room was prepared and proper coil selected( abdominal coil). In The MRI room the nature of the exam was explained to the patient .She was told about the noises she will hear, and the time the exam may take. She was asked to lay down on the MRI table in supine position in an orientation that head inserted first into the pore of machine and support foam was kept under knees for her comfort. Privacy and headphone devise (to minimise noise) was applied for the patient and she was handed a bile in case a problem occurs. Exam protocol and parameters were selected by technologist . Patient was instructed to breath normally while scanning. After finishing from the exam the patient wore her dress and was directed to go back to her doctor for any farther investigation and she was told to check the report with her doctor in the next visit. There was no complication during the procedure as the exam ran smoothly.

24 Images taken: (Coronal Sagittal and Axial) was first taken to check position, centring and level.

25 T2 Sagittal:

26 T1 sagittal:

27 STAIR sagittal

28 Myelo

29 Axial T2

30 Axial T1

31 Results of MDI – radiologist opinion:Straightening of lumbar lordosis (muscle spasm). Mild spondylitis showed as marginal osteophytotic. Degenerative changes seen at level L4-L5 , L5-S1. L4-L5 , L5-S1 posterior and posterior-lateral disc herniation. L3-L4 bulge Normal appearance of facet joints bilaterally with normal their joint space. Normal appearance of both sacro-iliac joints. No definite pre or paravertebral mass

32 Description of physicians' diagnosis:Low back pain radiated to left leg. Query L4/L5 disc.

33 Comparison of MDI & physicians diagnosis:The MRI sequences taken and radiologist report enhances the physician diagnosis that patient has got a : Disc problem between L4-L5 and more over L5-S1 This result enables the physcician to start the treatment for the patient.

34 Patient outcome Patient prognosis:Patient can proceed with her life if she followed the doctor’s prescription and advises. She will start recovering within a month, full recovery is expected within a few months period if she adhered to the physiotherapy sessions that are requested by the doctor along with the proper medication which are Olfen 50mg and muscular relaxant cream. Discussion of the effective of the MDI investigation used: the x-rays taken and the MRI enhanced the orthopedican’s opinion on the patient condition and gave full idea how patient problem look like and the exact location of the herniation. This full overview enabled the physician to prescribe the proper treatment and medication wether it is conservative or non-conservative solutions.

35 Conclusion: A 55 years old female patient Presented to orthopedician at the University Hospital Sharjah with low back pain and left leg ache. She was examined by the physician in the clinic, and she was suspected to have L5-S5 prolapsed disc. Consequently, patient was requested to undergo lab testing for her blood and urine to check if there are any abnormalities The patient was then scheduled for MRI L.Spine and the result revealed that there was disc prolapsed at two levels (L4-L5 and L5-S1) As treatment the physician has prescribed some nonsteroidal anti-inflammatory medications (NSAIDs) and narcotic painkillers and he requested four sessions of physiotherapy. The Physician expected the patient’s recovery to be very soon if she was fully compliant to the treatment.

36 References 1) 2)https://www.vsortho.com/patientresources/education/blog/intervertebral-disc-injuries-%E2%80%93-annular-tear 3) Toratora& Derrickson(2006) Principles of Anatomy and Physiology.11th edition, p225.John Wiley and Sons,Inc:US 4)https://patient.info/health/slipped-prolapsed-disc 5)http://www.back.com/anatomy-lumbar.htm 6)http://www.eorthopod.com/content/lumbar-spine-anatom y 7)http://health.nytimes.com/health/guides/disease/herenated-nucleus-pulposus-slipped-disc-prognosis.hml 8)http://www.spine-health.com/conditions/spine-anatomy/lumbar-spine-anatomy-and-pain 9)http://www.espalda.org/english/divulgativa/como_es_funciona/discos.asp 10)http://hjd.med.nyu.edu/spine/patient-education/spine-problems/back-and-leg-pain/lumbar-herniated-disc

37 Thank You !