Waist disease is a very common disease in modern times, in order to confirm the disease, lumbar CT has become a common and more safe and reliable means of examinationAccurately interpreting the results is a must-have skill for every doctor, but many doctors are not good at it, or do not know how to diagnose some uncommon, unskilled conditionsToday to share a case of missing lumbar CT, the content of classic, worthy of learning and learning!First look at the basic information of the case: medical history: female, 68 years old, lower back pain nearly 2 months, sexual aggravating, before and after admission to the hospital no obvious history of trauma, before chest 12 vertebrae old compression fractures, no bad habits, high blood pressure, normal limb muscle strength, free movement, push up the test mild positiveOrthopaedic clinicians initially diagnosed lumbar disc protrusion, and performed a lumbar ct scanCT image, lumbar vertebral conventional sequence scanning, lumbar vertebral body 2 layers, lumbar disc 4 layers, layer thickness 2.5mm, the general scanning range includes lumbar 2 - 1 vertebrae and the inter-discLumbar curvature slightly straightened, bone slightly hyperplifying, chest 12 vertebrae old compression fracture waist 4, 5 vertebrae and attachment bone mass did not see a change in the waist 2-3 disk did not see a change in the waist 3-4 disk bulging waist 4-5 disk bulge, Double-sided vertebral small joint gas waist 5 1 disk puffing, double-sided vertebral small joint gas CT report gives the impression of diagnosis is: 1lumbar vertebral mild hyperplifying 2chest 12 vertebrae archold compression fracture 3.waist 3-4, 4-5, waist 5 crucible 1 disc puff4-5, Waist 5,1 disc level two-sided vertebral small joint gas looks like a perfect diagnosis, lumbar vertebral bone growth, inter-disk expansion, vertebral small joint protrusion, support the performance of clinical lumbar painIf you think so, it's a big mistake!Then look down, the play is behind!
What did you find? The left vertical spine muscle is significantly swollen and full than the right side, and the intermuscular fat gap disappears!Reasons to think of: Trauma Infection (normal or specific inflammation) tumor (primary, secondary) 1Trauma: The patient has no clear history of trauma, even if there is trauma, so obvious swelling, multi-combined intramuscular hematoma, lumbar vertebrae and attachment fractures2Infection: Patients have no fever, no systemic infection symptoms, and infection is mostly caused by local skin damage, even if specific infections such as tuberculosis, aggression of one-sided muscle tissue is rare, and often accompanied by systemic tuberculosis poisoning symptoms 3 Tumor: Primary tumor is rare, cross-sectional fibroids, mostly occurred in children, and the site is mostly found in the skeletal muscle of the limbs Malignant fibroblastoma, more common in adults, to the elderly more, the age of onset is in line with, but most of the limitations of growth, mostly accompanied by bleeding, necrosis mucus degeneration, can have false envelope, more common in the adult limb of the deep soft tissue Secondary tumors are less common, and the spread of primary malignant bone tumors or vertebral metastatic tumors that are more secondary to adjacent vertebral bodies is infested What kind of devil???
Finally know what the ghost is in disorder, found the left vertical spine swelling cause: lung cancer metastasis Reason for missed diagnosis: 1 Observation of blind spots: lumbar screening only focused on observing lumbar vertebral and attachment bone, lumbar disc, vertebral tube conditions, ignoring the observation of peripheral muscle tissue, which is the root cause of the missed diagnosis 2 Scanning and imaging methods are inherently inadequate: sequence segmented scanning and segmented imaging methods, so that the continuity of the lesions interrupted, vertebral bone window and inter-disk soft tissue window alternate imaging, single axial observation, lesions without continuity and lack of three-dimensional sense 3 Limitations of clinical thinking: insufficient understanding of the causes of low back pain in the elderly, limited to lumbar vertebral degeneration, fractures, interplate bulging protrusion, vertebral tube stenosis, etc., lack of understanding of primary and secondary tumors in the lower back, over-reliance on information provided by clinicians Malignant tumor intramuscular metastasis is relatively rare, and there is a lack of understanding of this Revelation: Reading the film to be careful, in strict accordance with the lumbar vertebrae, interdiscery, vertebral tube, soft tissue order, from the top down, the two sides of the contrast observation, a little more patience, details determine success or failure Improved CT scanning and imaging methods, the whole process using spiral scanning, late three-dimensional reconstruction, bone window and inter-disk soft tissue window separate reconstruction, sadum, coronal, axial position imaging observation, intuitive three-dimensional, do not leave blind spot Strengthen the comprehensive understanding of the causes of lower back pain in the elderly, use clinical signs to guide the image, use the image to explain the clinical Lum metastasis tumors, bone metastasis and mixed metastasis, to prostate cancer and breast cancer, bone-soluble metastasis to lung cancer, mostly blood metastasis, to violation of vertebrae and attachment bone-based, and then can affect adjacent soft tissue, and soft tissue metastasis as the primary performance, lumbar vertebrae and attachment bone changes are not obvious, clinical and video are relatively rare The correct reading method with lumbar CT: 1 normal form of lumbar spine: L1-2 to L4-5 intervertebral disc form is similar, is kidney-shaped, the hind edge young person slightly concave, the depression and the hindpart ligament walk is consistent, with the age of the age, the back edge can become straight; Normal L5-S1 disc's back edge is straight, and can be slightly puffed out; the intervertebral disc is composed of myelin and fiber rings, slightly higher than the soft tissue density shadow, CT value is 80 to 120HU, CT can not distinguish the myelin core and fiber ring; The rear is the vertebral small joint, the upper and lower is the vertebral arch root, the inner and lower hidden nest is connected, there is the spinal nerve root through; side hidden nest: downward outer extension in the vertebral hole, there is the spinal nerve pass - the front wall is the outer edge of the vertebrae - the back wall is the upper joint protrusion front and yellow ligament - the outside world is the vertebral arch root; the normal front and rear diameter is 3-5mm, 3 mm side hidden nest, 5mm narrow, not narrow
2 Anatomy of the intervertebral disc and its accessories: vertebral: L1 to L5 volume increasing vertebrae arch root: longer and wider than thoracic spine, oval echidna: horizontal, square transverse: larger than thoracic vertebrae: large, but the risk of nerve root pressure increases vertebrae: large enough to accommodate the shape of the horsetail and nerve root lumbar segment: from top to bottom for the---- ovuls --- triangular triangular three-leaf 3 Reading focus: look at the general situation: vertebral physiological curvature, vertebral body number, vertebral form, lumbar angle, vertebral gap and so on Physiological curvature: normal lumbar spine is front convex, see if there is a straight, anti-zhang, dislocated, slip Number of vertebrae: normal is 5, to see if there is lumbar lumbar or lumbar vertebral palladization Vertebral morphology: to see whether the vertebrae is complete, whether there is deformation, compression, crushing; Vertebrae gap (side hidden nest): whether the vertebrae gap is uniform, such as large, whether there is a narrowness Intervertebral disc: there is no degeneration, whether there is puffout, protruding, out Intervertebral tube: there is no jaundice ligament thickening, narrowness Waist angle: normal 34 degrees The focus is on the intervertebral disc, the vertebral gap, the vertebral tube 4 Structures associated with the reading of CT tablets: intervertebral discs (fibre rings and myelin), intervertebral tubes, epidural sacs, spinal cords, nerve roots
5 Combined with CT and illustration to see part of the intervertebral disc lesions: intervertebral disc protruding sideways, not compression of the spinal cord, but side hidden nest stenosis, has compressed nerve root intervertebral disk side central type protruding, has compressed the epidural sac, spinal cord pressure intervertebral disc after the central type and side Side-shaped prominent, near-epidural sacs and side hidden nestS This article Source: This article is a comprehensive finishing for good medical authors, part of which comes from the director of Yu Changfu (Princess Ling City Third People's Hospital) courseware Author: Good medicine, a good neurology channel good medicine