Low back pain

One of my closest friends has had several back issues throughout her life. She used to be a competitive figure skater. For starters she has a history of a healed compound fracture of L-3 that was just diagnosed, which has caused some wedging of the vertebra. When she was eleven, she was diagnosed with scoliosis from L-3 through L-5 due to repetitive trauma to her growth plate of the left hip from her skating. The fifth lumbar vertebra is taking the same form of the sacrum causing what is called L-5 sacralization. (The image on the right shows an example of this.) And if matters couldn't get worse, she also has spina bifida occulta, which is where the spinous process on the inside of the vertebra is not closed properly. My friend is actually very lucky, because in some cases, spina bifida occulta can lead to huge deformities of the legs, feet (an example is clubfoot), and the spine making the patient unable to walk or walk without the use of a walking device. Throughout her whole life, she has had numerous MRI scans to monitor her condition.

What I found most interesting when talking with her, is that patients with spina bifida occulta can have several conditions that result from having this disorder. Some of these conditions are: UTI's, skin infections, and skin allergies.

She has tried several means of management to minimize pain and mazimize daily function. Initially, after the growth plate injury, she tried physical therapy with ultrasound and rest. She also was fitted for orthotic inserts to build her left side up to match the right so she doesn't walk crooked. Then she tried occupational therapy or "spinal re-training". She even had a cortisone injection under fluoroscopy, but unfortunately, it didn't help. Today, she uses a combination of chiropractic care, massage therapy, and a TENS unit (trans-cutaneous electro-neuromuscular stimulation). All of these treatments have helped tremendously with the pain and spasms, but she occasionally has to resort to using oral pain medication. Thankfully my friend has never had to have surgery, but some patients with these deformities have to undergo the knife, especially with severe cases of spina bifida occulta or growth plate trauma.

References:

www.ajronline.org

Compression fracture of the T-spine

A compression fracture is when one bone is broken and pressing up against another bone. A great example of this is the vertebral column of the thoracic spine. Compression fractures can be caused from various reasons. One of the most common is osteoporosis, which is bone thinning and usually happens in post menopausal women. Other reasons are METS (metastatic cancer), falling, lifting injuries, and even coughing or sneezing.

There are several different ways of treating this condition. Giving the patient NSAIDS (non-steriod anti-inflammatory drugs) will help with the inflammation and some pain. I found it very supprising that WebMD said, "anti-depressants can also help relieve nerve related pain." Simply wearing a brace can also help or patients could go a completely different route and have surgery done. Kyphoplasty is probably on of the most common types of surgery. It is where the physician injects a substance of bone acrylic in the vertebral body to help stabilize it. The patient must have a new fracture to have this type of procedure done. Vertebroplasty is very similar to kyphoplasty, but it does not use an inflated balloon to help position the vertebral height. Spinal fusions and bone grafts are other methods of treating this condition.

References:

Images: www.iofbonehealth.org

WebMD.com

Cervical disc herniation

My father was involved in a motorcycle accident about 15 years ago, but since his accident he has had terrible back trouble. He had had seven back surgeries since his accident. In 2007, he was complaining numbness, tingling, and decreases sensation in his left arm, thumb, index, and middle fingers and a lot of pain in his neck that wouldn't go away. His MRI showed foraminal narrowing in C4-T1 area and he was also diagnosed with radiculopathy, which is where the nerves become inflamed by disc herniation. A disc herniation is where the nucleus pulposus (the center of the disc) is squeezed out of a torn annulus (the coating around the nucleus pulposus) and pushes out into the spinal canal. His doctor suggested an epidural steroid injection, but my dad refused because steroid injections have never worked for him in the past. After reviewing over possible alternatives, my dad decided to have a cervical spine fusion of C5-C6 and C6-C7. My father, thankfully, did not have any major risks from the surgery besides decreased range of motion and pain. According to my fathers' surgeon blindness, paralysis, difficulty swallowing, voice changes or damage to vocal cords, infection, esophageal injury, decreased blood, and dural tears are all possible outcomes from having a spinal fusion.

Only about 1 in 10 people have to have surgery, according to the mayo clinic. Other alternatives for disc herniation are medication, exercise, stretching, wearing a brace, etc.

I have uploaded an image of a disc herniation example from www.health-res.com.

Aneurysms

A patient arrives in the ER with major headaches and is very confused. She had just given birth to twins three weeks prior and a history of high blood pressure. After being evaluated by the ER doctor, it was noticed that her blood pressure was extremely high. A CXR and CT head was completed and showed a ruptured aneurysm and a subarachnoid hemorrhage. The patient was immediately transferred to the ICU where they could make her stay more comfortable, because at this point she was pretty well brain dead. What is an aneurysm? It is a bulging in a blood vessel, which can occur anywhere, but happens more often in the aorta and the brain. The patient that I helped to treat had a brain aneurysm, which means that the blood pooled between the brain and the brain covering. Some symptoms include a sudden headache, confusion, blurred vision, loss of consciousness, nausea, vomiting, etc. According to the Mayo clinic, "50% of ruptured aneurysm are fatal". Aneursms are caused from a thinning in the vessel wall. Common risk factors are age, genetics, HBP, smoking, increased alcohol consumption, AVM's (as recently discussed in a previous blog), and low estrogen levels. Patients who chose not to breastfeed, estrogen and prolactin levels decrease after pregnancy. Imaging modalities that are used are CT, MRI, and angiography to visualize blood vessels. Aneurysms can sometimes be fixed by using an aneurysm clip to clip off the bulge or an endovascular coil can be placed within the vessel. Certain medications for HBP, calcium channel blockers, or vassopressors may be used to decrease the chances of having an aneurysm. Risks can be decreased by not smoking, exercising, eating a healthy diet, and decreasing caffeine and aspirin intake.

References:
mayoclinic.com
babyboomercaretaker.com
ideasforsurgery.com

Hodgkin's lymphoma

I once had a 22 year old male patient came in to the urgent care that complained of swollen lymph glands in his neck and right shoulder area for approximately one week. His main concern was that the lymph glands got very large in a short period of time. The doctor I was working with ordered a mono test, CBC (complete blood count), a CMP (complete metabolic panel), an influenza test, and x-rays of the chest and soft tissue neck. All of the in house labs came back normal, but his white blood cell count was extremely high, and his x-rays showed swelling of the lymph glands all the way down to almost the hilar area. After the doctor reviewed his test, he sent the patient to have a STAT CT scan of the chest. The patient was allergic to contrast, so a non-contrast exam was done. The impression of the scan was, "Anterior mediastinal and right peritracheal lympadenopathy as well as supraclavicular adenopathy and the radiologist suggested the patient see an oncologist to do further testing to rule out cancer. After visiting the oncologist, a biopsy was performed and was confirmed as Hodgkin's Lymphoma. The patient went through numerous radiation therapy and chemotherapy treatments and is now cancer free!

Lymphoma's are cancers involving the lymph system. There are two major types of lymphomas, one being non-Hodgkin's lymphoma and the other being Hodgkin's lymphoma. Non-Hodgkin's lymphomas are more aggressive so the treatment for those patients are stronger. Patients with Hodgkin's lymphoma have a high survival rate especially when caught early. CT, MRI, and PET scans are usually the imaging choices and the first step in determining the problem. After the initial scans, a biopsy is taken out of the area of interest and a "stage" is given to the type of cancer, if any. There are 4 stages of cancer. Stage 1 is when the cancer is found early and stage 4 is later and more complex. Some risk factors include: being male, an infection with the Epstein Barr Virus (mono), and a weakened immune system. Treatments for Hodgkin's lymphoma is chemotherapy, radiation therapy, or mixture of both, which depends on age, gender, severity of cancer, etc. I have uploaded an image of Hodgkin's lymphoma on CT soft tissue neck.

References:

http://www.mikety.net/X-rays/HL-neck-a.jpeg

http://www.lymphomainfo.net/hodgkins/description.html

AVM's

Arteriovenous Malformations, or also known as AVM's, are when an artery and vein connect. There are no known causes for this abnormality, but they are congenital. More often, AVM's occur in the brain, but can happen anywhere. Most of the time people with AVM's have no symptoms, unless the blood vessel leaks causing a hemorrhage. If this happens, patients develop headaches, seizures, possible vision or hearing loss, etc. However, there are other complications that may happen with AVM's such as decreased oxygen level to the brain, weakened blood vessels, or even brain damage! Although AVM's are more common in boys than in girls, pregnancy may cause a patient to start developing symptoms. Patient younger than 50 are also at an increased risk to progress signs of having an AVM.

Even though cerebral arteriography is the preferred imaging modality, MRI and CT imaging may also be used. Contrast may be given to the patient to enhance the vessels in either modality to show where the pathology is. I have uploaded images to show what an AVM looks like. One section is MRI images, the other is CTA images.

Treatment includes surgery, radiation treatment (to actually clot the vessels), or embolization (where a catheter is put into an artery in the leg then to where the AVM is and a substance is injected into the catheter to decrease flow of blood).

References:

http://mayoclinic.com/health/brain-avm

http://stanfordhospital.org/ImageGallery/images

Rhinolith

Rhinolith is literally translated as a "Nose stone". It is a calcification found inside the nasal cavity caused from the accumulation of mineral salt (from tears or nasal drainage) that forms around either a exogenous object, such as a piece of cloth or foreign body, or as an Endogenous object, which could be a blood clot or a lump of mucus. The material hardens and as the mineral salt adds to it, it gets larger causing the patient to have difficulty breathing and some pain. Females are more prone to getting a rhinolith.

Treatment for a rhinolith is simple. The stone is taken out in surgery and if the stone is large enough, it is broken up into pieces and then taken out.

Here are some pictures I found on the websites below. It is amazing to see how big "nose stones" get.

References:

http://www.thefreelibrary.com/Rhinolith-a01073751348

http://www.scielo.br (picture #1)

http://www.ghorayeb.com/Rhinolith.html (picture #2)

Blow out fractures

Blow out fractures are fractures that are caused by a blunt force applied to the orbit. The fracture usually occurs within the orbital floor because it is the thinnest part of the orbital wall. Hemorrhaging of blood into the sinus cavity is evidence of a fracture in the floor of the orbit. Orbital emphysema may also be another side effect of this fracture. It is due to the leakage of air into the sinus cavity (usually occurs within the ethmoid sinuses).

One of the fractures that I find the most interesting is called a tripod fracture or a zygomaticomaxillary fracture. This type of fracture basically separates the zygomatic bone from the frontal and maxillary bone leaving a triangle shape, hence the name. Not only does this fracture sometimes cause facial deformity and the patient must have surgery, it may also cause an impingement on the optic canal. Patients may also complain of difficulty eating or blowing their nose. The diagram on the bottom and the picture on the 3-D image on the top are examples of tripod fractures.

A few years ago a patient got in a fight and was punched in the face several times and came in to the hospital to be evaluated. The ER doctor ordered a general facial bone series, but because plain radiographs were not sufficient enough, he was sent to have a CT scan done. He was given a diagnosis of a left tripod fracture and a fracture of the nasal bone.

References:

http://www.rad.washington.edu/academics/academic-sections/msk/teaching-materials/online-musculoskeletal-radiology-book/facial-and-mandibular-fractures

Eisenberg, Ronald M.D., J.D., F.A.C.R. & Johnson, Nancy, B.A., RT(R) (CV) (CT) (QM).
3rd Ed. 2003. Nervous System. Woodard, Linda Eds. Comprehensive Radiographic
Pathology. (pp 322-323). Missouri: St. Louis.

radiology.uiowa.edu/downloads/

Prolactinoma

What is prolactinoma?

It is a non cancerous pituitary tumor that causes an overproduction of the hormone prolactin. The prolactin hormone stimulates the production in breast milk and it also is in charge of breast development.

Causes of prolactinoma are unknown, but there are several risk factors including individuals who have hypothyroidism, pregnant women, young women, and older men. Results can range anywhere from loss of vision (due to the tumor compressing on the optic nerve), bone loss, and headaches, to lactating from the breast (from the overproduction of prolactin), hypothyroidism, and decrease in other hormones released by the pituitary gland.

Medications are usually given to help regulate hormone levels, but in some rare cases, the tumor must be excised in surgery. I have included an example of a prolactinoma on a CT coronal image with contrast.

References:

www.radpod.org

www.mayoclinic.com

http://www.medi-fax.com/atlas/braintumours/pituitarytumors/case2.html

Bell's palsy

My last post was about a patient with MS plaques, but that same patient also had a meningioma against the mastoid air cells on the left side. I really didn't want to write about the same patient, so I did some research and I was very interested in Bell's Palsy.

I work as an x-ray tech/MA at an Urgent Care. A few days ago, we had a patient come in with symptoms of left sided numbness and weakness and a headache behind the left ear. When the patient would squint, her left side would not squint as well as the right and when she tried to open her mouth, her left side would not open as much.

After the doctor had told me her diagnosis, I began to ask lots of questions. My patients' diagnosis was, of course, Bell's palsy. Bell's palsy is a paralysis of the seventh cranial nerve (facial nerve). It could be the consequence of a tumor, stroke, infection, swelling, etc. When I got home I did more research and found that the most common cause of Bell's palsy is the herpes simplex virus (HSV).

Most of the time the symptoms will go away on its own, but for some unlucky patients surgery may be their only option. My patient, however, was prescribed prednisone to help with the swelling of the nerve. Hopefully her symptoms will start to dissipate, but only time will tell.


References:

http://mayoclinic.com/

http://yassermetwally.files.wordpress.com/2009/01/bell.jpg

multiple sclerosis

A patient came in the other day with a known history of Multiple Sclerosis and right leg numbness X 2 years. His PCP ordered an MRI brain with and without contrast. I noticed when scanning without contrast there were tiny areas that were dark in T1 (low signal) and bright in T2 and Flair (high signal). After injecting contrast the areas I noticed got brighter or enhanced in T1. With the patients known history of the disease, the Radiologist read this exam as active MS. (Active MS because when injecting contrast, the new lesions were highlighted. If the lesions were old, they would not be highlight).

Multiple sclerosis is a central nervous system disease that breaks down the myelin sheath. It unfortunately is found mostly in young adults; especially women. MS doesn't only occur in the brain, it also occurs in the spinal cord and depending on where it is located and how big the lesion is determines the patients symptoms.

MS effects everyone differently. Common symptoms include: loss of vision, numbness of extremities or parts of the body (like my patient), urination problems, slowed thinking, and etc. Because each person is effected differently by MS, it can be extremely hard to diagnose. Therefore, the best way to diagnose MS is through the use of MRI with and without contrast.

References:

http://www.wendys-ms-site.com/whatis.html

Intro

My name is Lacey. I'm an x-ray tech in Indianapolis and I'm very excited to start MRI rotations this semester. I will keep you posted with all the cool things I get to see in MRI's and CT's!!