Vertebral Fracture Classification By Advanced Imaging Jalal Jalal Shokouhi-M.D. General secretary of ISR (Iranian society of radiology)

MRI might change vertebral body fracture classification

Special thanks to: Rahimi Zadeh –MD Khadivi –MD Ali Akbar Ameri –MD Gholamreza Bakhshande pour –MD Hamid Mohammad pour –MD

A: Compression fractures: A1 : Impaction: A1.1=Endplate infraction A1 : Impaction: A1.1=Endplate infraction A1.2=Wedge fracture A1.2=Wedge fracture A1.3=Body compression A1.3=Body compression A2: Split A2: Split A3: Burst A3: Burst B: Flexion/ Extension injury C: Rotation injury

T-Score/Z-Score/BMD/WHO

* Intact posterior column * Intact posterior column

Flow diagram for determining the type level of the AO classification

RN Scan

FRACTURE EVALUATION X-Rays CT Scan MRI MRI Miscellaneous Miscellaneous

X-Ray Advantages of x-rays:Advantages of x-rays:--Inexpensive --Easy to obtain --Past A-P or lateral images can be compared to present images. compared to present images. --Gross bony morphology changes can be detected quickly. be detected quickly.

X-RAY Disadvantages of x-rays:Disadvantages of x-rays: --Fracture must be collapsed to identify VCF. VCF. --Age of fracture indeterminate. --Osteopenia, scoliosis, and obesity will limit bony resolution. limit bony resolution. --Difficult to detect middle column and posterior column fractures. posterior column fractures.

CT SCAN CT Scan--also known as CAT/TAC scan. Computed Axial Tomography. Uses a beam of radiation which moves in an arc to create an image.CT Scan--also known as CAT/TAC scan. Computed Axial Tomography. Uses a beam of radiation which moves in an arc to create an image. Spiral CT Scan--allows for quicker assessment (20-30 sec.) of anatomic regions. Can obtain 3D images.Spiral CT Scan--allows for quicker assessment (20-30 sec.) of anatomic regions. Can obtain 3D images. Bone Scan--Identifies metabolic bone activity.Bone Scan--Identifies metabolic bone activity.

CT/CAT SCAN Advantages:Advantages: -- Used with Burst fractures to assess -- Used with Burst fractures to assess bone fragments in the canal. bone fragments in the canal. -- AP view allows you to see the fracture plane -- Easy to obtain, almost always taken for trauma Disadvantage:Disadvantage: --Insensitive to edema --Age of fracture indeterminate

CT In trauma

CT In trauma same pt.

Is this a case for Kyphoplasty? What questions would you ask the doctor?

MRI AdvantagesAdvantages –High resolution, sensitivity and specificity –Can be useful for identifying micro- fractures. –Better for assessing tissue damage, tumors and infection

MRI Disadvantages:Disadvantages: --Very costly --Time consuming --Patient claustrophobia --Difficult to differentiate posterior element fractures element fractures

MRI T1 - oedema is darkT1 - oedema is dark T2 - oedema is bright but not always visible (can be obscured by fat.)T2 - oedema is bright but not always visible (can be obscured by fat.) STIR – Short Tau eliminates all fat to only show fluidsSTIR – Short Tau eliminates all fat to only show fluids STIR is always the best image to use for determining if the fracture is freshSTIR is always the best image to use for determining if the fracture is fresh

MRI T1STIR S.T.I.R. = Short Tau Inversion Recovery T2

What is at T7?

MRI AND X-RAY

Candidate for Kyphoplasty????

Lateral FX.

Enostosis or bone island or bone stone What is your diagnosis? No need kyphoplasty No need kyphoplasty

500 Traumatic Patients 147 Fractures 2 Cases of Spinal puncture or Dural tear Common fractures are anterior wedging and upper end plate depression Fractures: Single,2-3,5 Gold standard: MRI WITH STIR CT is better for V.Body processes

Thank You