THE SPINE IN HEALTH AND DISEASEVenue: British Dental Association, London

CPD: 6 CREDITS

21 JANUARY

2015

More information available soon at www.bir.org.uk

• Room1Primers for the non-specialistsSessionorganisedbyDrDavid

Wilson,ConsultantInterventional

MSKradiologist,OxfordUniversity

HospitalsNHSTrust

• Room2Radiation protectionSessionorganisedbyMrAndy

Rogers,HeadofRadiationPhysics,

NottinghamUniversityHospitals

NHSTrust

Save the date

• Room1Clinical hybrid imaging inoncologySessionorganisedbyDrGopinath

Gnanasegaran,Consultant

PhysicianinNuclearMedicine,

StThomas’Hospital

• Room2Trauma imagingSessionorganisertobeconfirmed

Essentials for the radiology traineeSessionorganisedbyDrHardi

Madani,RadiologyRegistrar,

RoyalFreeLondonHospital,and

DrAusamiAbbas,Cardiothoracic

RadiologyPostCCTFellow,

UniversityHospitalAlberta

Day 2Day 1

BIR ANNUAL CONGRESS 20154–5 NOVEMBER

LONDON

We are most grateful to

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Save the date

Day 2

Welcomeandthankyouforcomingto‘Thespineinhealthanddisease’organisedbytheBritishInstituteofRadiology.

Wewishyouaveryenjoyableandeducationalexperience.

Certificateofattendance

Thismeetinghasbeenawarded6RCRcategoryICPDcredits.

Yourcertificateofattendancewillbeemailedtoyouwithinthenexttwoweeksonceyouhavecompletedtheonlineeventsurveyat:

https://www.surveymonkey.com/s/TheSpine

BIR Annual Congress 2015: 4–5 November, London

We are most grateful to

for supporting this conference.

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Programme

09:00 Registration and refreshments

09:25 Welcome and introduction DrTuhinSikdar,ConsultantRadiologist,PrincessAlexandraHospital

09:30 Anatomical considerations in the spine DrDimitriAmiras,ConsultantRadiologist,ImperialCollegeHospitals

09:50 Embryology and development of the osseous spine ProfessorFilipVanhoenacker,ConsultantRadiologist, UniversityAntwerp,Belgium

10:10 Spinal infections DrThillainayagamMuthukumar,ConsultantMusculoskeletalRadiologist, RoyalNationalOrthopaedicHospital

10:30 Tumour-like conditions of the spine DrAsifSaifuddin,ConsultantMusculoskeletalRadiologist, RoyalNationalOrthopaedicHospital

11:00 Refreshments

11:20 Degenerative disorders DrThillainayagamMuthukumar,ConsultantMusculoskeletalRadiologist, RoyalNationalOrthopaedicHospital

11:45 Seronegative spondyloarthropathies DrMariannaThomas,ConsultantRadiologist,RoyalUnitedHospital

12:15 DISH, OPLL and other ossific/calcific conditions in the spine ProfessorFilipVanhoenacker,ConsultantRadiologist, UniversityAntwerp,Belgium

12:40 Discussion

12:50 Lunch

13:30 Spinal tumours DrAsifSaifuddin,ConsultantMusculoskeletalRadiologist, RoyalNationalOrthopaedicHospital

14:00 Vertebroplasty: where are we now? DrDamienTaylor,ConsultantRadiologist,HullandEastYorkshireHospitals

14:30 Cervical spine trauma DrPrudenciaTyrrell,ConsultantRadiologist, RobertJonesandAgnesHuntHospital

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15:00 Refreshments

15:20 Thoracolumbar spine trauma DrTuhinSikdar,ConsultantRadiologist,PrincessAlexandraHospital

15:40 Spinal intervention: how I do it DrDamienTaylor,ConsultantRadiologist,HullandEastYorkshireHospitals

16:10 The post-operative spine DrPrudenciaTyrrell,ConsultantRadiologist, RobertJonesandAgnesHuntHospital

16:40 Questions and discussion

16:45 Close of event

_______________________________________________________________________

Certificate of attendance

Thismeetinghasbeenawarded6RCRcategoryICPDcredits.

Yourcertificateofattendancewillbeemailedtoyouwithinthenexttwoweeksonceyouhavecompletedtheonlineeventsurveyat:

https://www.surveymonkey.com/s/TheSpine

BIR Annual Congress 2015: 4–5 November, London

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Speaker profiles

Dr Dimitri AmirasConsultant Radiologist, Imperial College Hospitals

DrAmirascompletedradiologytrainingatCharingCrossandHammersmithHospitalwithsubspecialisationinmusculoskeletalradiology.AftercompletinghisradiologytrainingandinitialsubspecialisationhefurtheredhistrainingwithfellowshipsinFremantleHospital,WesternAustraliaandobservershipsattheAcademicMedicalCentreinAmsterdamandAucklandCityhospitalinNewZealand.

DrAmirasisakeensportsmanwithinternationalrugbycapandanAIDAqualifiedfree-diver.

Dr Thillainayagam MuthukumarConsultant Musculoskeletal Radiologist, Royal National Orthopaedic Hospital

DrMuthukumarqualifiedfromIndiainmedicinewithapost-graduatedegreeinradiologyfromNagpurUniversity.Subsequently,heunderwent2yearstrainingattheChristianMedicalCollegeHospitalatVellore.HejoinedtheradiologytrainingschemeattheAberdeenRoyalInfirmaryfollowedbyafellowshipinmusculoskeletalradiologyattheRobertJonesandAgnesHuntOrthopaedicHospitalatOswestry.

HejoinedasConsultantMusculoskeletalRadiologistattheRoyalNationalOrthopaedicHospitalin2005.Hisactiveinterestsareininterventionalmusculoskeletalradiology,complexspineandsarcoma.Hedealswithsportsinjuriesofinternationalfootballersandcricketers.HeisalsoanhonoraryvisitingprofessortotheTamilNaduDrMGRMedicalUniversityinChennai.

Dr Asif SaifuddinConsultant Musculoskeletal Radiologist, Royal National Orthopaedic Hospital

DrAsifSaifuddinistheseniorMusculoskeletalRadiologyConsultantattheRoyalNationalOrthopaedicHospitalNHSTrust,wherehehasbeeninpostsince1994.Hismajorinterestsareinmusculoskeletaltumourimagingandspinalimaging.Hehasauthoredover200papers,severalbookchaptersandalsothetextbookMusculoskeletalMRI,publishedin2008.

Dr Tuhin SikdarConsultant Radiologist, Princess Alexandra Hospital

DrTuhinSikdarisConsultantRadiologistatPrincessAlexandraHospital,Harlow,Essex.Hehasspecialinterestsinmusculoskeletalradiologyandnon-vascularintervention.HeisClinicalTutorfortheEastofEnglandDeaneryandcommittedto

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postgraduateeducationinradiology.

HissurgicaltrainingwasintheNewcastle-upon-TynegroupofhospitalsandheobtainedtheFRCSin1989.HistraininginRadiologywasattheCharingCrossandHammersmithHospitals,nowpartoftheImperialCollegeHealthcareNHSTrustLondon,andlateratRoyalNationalOrthopaedicHospitalinStanmore.

HehasdevelopedakeeninterestinmusculoskeletalinterventionandMRandhasconductedandcontributedtospinalinterventionworkshopsinternationally.HeisanenthusiasticmedicaleducatorregularlycontributingtorevisioncoursesforradiologyandorthopaedictraineesandorganisingeducationalmeetingsfortheBritishInstituteofRadiologywherehewasconferredHonoraryFellowshipin2012.

Dr Damien TaylorConsultant Radiologist, Hull and East Yorkshire Hospitals

DrTaylortrainedinBristolandworkedasaSeniorRegistraratCharringCrossHospitalintheearly1980’s.HehasbeenaConsultantRadiologistinHullsince1987whichisnowpartoftheHull/YorkMedicalSchool.HeisanactivememberoftheBSSR.HeisClinicalLeadinMSKimagingforhisTrust.

Hehaspioneeredvertebroplastyandhaslecturedonthesubjectextensively.Healsohasamajorinterestinallformsofspinalintervention,inlcudingbiopsyandpainreliefprocedures.

Hehopestosharehisexperienceswithyouandintroduceyoutosomenewtechniques.ThespinalinterventionlecturewillbededicatedtoDrBillParks.

Dr Marianna ThomasConsultant Radiologist, Royal United Hospital

MariannaThomasisaConsultantRadiologistattheRoyalUnitedHospitalBathFoundationTrust,includingtheRoyalNationalHospitalforRheumaticDisease.

HavingqualifiedfromUniversityCollegeLondonmedicalschoolandcompletedsubsequentpostgraduatetraining,shewentontospecialtyRadiologytrainingintheEastMidlandsDeanery.SheundertookafellowshipinMusculoskeletalRadiologyatNorfolkandNorwichUniversityHospitalpriortostartinginhercurrentpostin2013.

Dr Prudencia TyrrellConsultant Radiologist, Robert Jones and Agnes Hunt Hospital

DrPrudenciaTyrrellisaConsultantMusculoskeletalRadiologistattheRobertJonesandAgnesHuntOrthopaedicHospital,Oswestry,aspecialisttertiaryreferralorthopaedichospital.Shewasappontedin1995.Herspecialinterestsincludethespineandalsoboneandsofttissuetumours.

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Professor Filip VanhoenackerConsultant Radiologist, University Antwerp, Belgium

ProfessorFilipVanhoenackerbecameaSpecialistinRadiologyin1991andisnowaConsultantRadiologistandLectureratUniversityAntwerpandaGuestProfessorattheUniversityofGhent.

Hehasbeentheco-authorandco-editorofnumerousbooks,including‘MedicalImagingoftheSpleen’and‘ImagingofSoftTissueTumors’.Hewasalsothemaineditorforthebook‘ImagingofOrthopedicSportsInjuries’.

Heisamemberofmanydifferentradiologicalsocieties,includingAmericanRoentgenRaySociety,ECR,RoyalBelgianSoietyofRadiology,EuropeanSocietyofMusculoskeletalRadiology(ESSR),ISS,AmeriacanSocietyofSpineRadiology,andacorrespondingmemberofRSNA.Inaddition,hehasactedastheSecretaryandPresidentoftheOsteo-articularsectionoftheRoyalBelgianSocietyofRadiology,andCounsellorandEducationalCommitteeChairmanoftheESSR.

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Abstracts

Anatomical considerations in the spineDr Dimitri Amiras

Thespinalanatomyrepresentsmillionsofyearsofevolutionfrominvertebratestovertebratestobipedalhominids.Thislectureintendstogiveagentlereviewoftheosteology,discal,muscular,ligamentousandneuralanatomywithsomereferencetoyourvertebratecolleaguesandsomeclinicalexamples.Therewillbeaspecificfocusondiscalanatomyandcorrespondinganatomyofthenervoussystemandterminology.

Embryology and development of the osseous spine Professor Filip Vanhoenacker

Thedevelopmentofthevertebralcolumncomprisesofthreemajorstages,theprecartilaginousstage,thecartilaginousstageandfinallythebonystage.

Theprecartilaginous stageormesenchymalstagestartsatweekfouroffoetallifewithsclerotomeformationfollowedbyresegmentationofsclerotomes.

Thecartilaginous stage(chondrification)beginsatweeksixoffoetallife.

Thebony stage(ossification)startsduringtheembryonicperiodandiscompletedbytheageof25.

Attheendoftheembryonicperiod,3primaryossificationscentersappear,i.e.inthecentrumandineachhalfofthevertebralarch.

Atbirth,eachvertebraconsistsofthreeosseouspartsconnectedbycartilage.Thevertebralarchhalvesfusesat3-5yearofage.Fusionoftheposteriorelementsoccursfirstatthelumbarregionandspreadsthencranially.

Atpuberty,fivesecondaryossificationcentersarepresent,i.e.tworimepiphysesatthesuperiorandinferiorvertebralbodyrespectively,attipofeachtransverseprocessandoneatthetipofspinousprocess.Fusionofthesesecondaryossificationcentersiscompletedattheageof25.

Errorsinformation,resegmentation,chondrificationandossificationmayresultinmorphologicalanomaliesofthevertebralcolumn.

Duringthefetalperiod,thenormalcurveofthevertebralcolumniskyphotic.Duringinfancy,cervicallordosisdevelopsasthechildisholdingitsheadupright,whereaslumbarlordosisdevelopssecondarilyduetosittingandstandingposture.In95%ofthepopulationsevencervicalvertebrae,twelvethoracicvertebrae,fivelumbarvertebraeandfivesacralvertebraarepresent.In3%ofthepopulation,oneortwoadditionalvertebraeareseen,whereas2%haveless.

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Learningobjectives:• Tosummarisethedifferentstagesindevelopmentoftheosseousspine• Toillustratehowerrorsoftheseembryologicstepsmayresultincongenital

abnormalitiesandvariants

References:• KaplanKM,SpivakJM,BendoJA(2005).Embryologyofthespineand

associatedcongenitalabnormalities.SpineJ.5(5):564-76.• SchoenwolfGC,etal.(2009).Larsen’sHumanEmbryology,4thEdition,

ChurchillLivingstone,Elsevier.• http://web.indstate.edu/thcme/duong/EMBRYOL.html#anchor59130

Spinal infectionsDr Thillainayagam Muthukumar

Thepathoanatomicprocessesinspinalinfectionwillbereviewed.Thedifferentimagingappearanceswillbedemonstrated.Radiologicalmanagementofsuspectedspinalinfectionwillbediscussed.

Tumour-like conditions of the spineDr Asif Saifuddin

Forthepurposesofthispresentation,non-neoplasticlesions(NNL)ofthevertebralbodyincludeallthosefocallesionsthatmaybeidentifiedonspinalimagingthatcanmimicbenignormalignantvertebraltumours,excludingacutespinaltrauma.Suchlesionsmaybepresentwithspinalpainbutrarelywithanyassociatedneurologicaldeficit,ortheymaybeidentifiedincidentally.Theycanalsobesolitary,andthereforebemistakenforprimarytumours,ormultifocalandbemistakenformetastaticdisease.However,themajorityhaveclassicalimagingfeaturesonacombinationofradiography,MRIandCTthatcanallowaconfidentdiagnosiswithouttherequirementforneedlebiopsy.

Suchlesionsmayrepresentnormalvariantsorbedegenerative,traumatic,infectious,inflammatoryormetabolicinnature.Normalvariantsofmarrowincludefocalmarrowhyperplasiaandthegiantnotochordalrest.DegenerativelesionsincludediscogenichemivertebralsclerosisandtherarevariantsofSchmorl’snodes.Traumaticcausesincludebenignosteoporoticcollapse,whichmustbedifferentiatedfrompathologicalcollapse.Infectionsmimickingtumourincludecasesofosteomyelitiswithoutdiscinvolvement,mostcommonlyTBwhichcanbemultifocalsimulatingmetastases.Inflammatorylesionsincludethevariouscausesofspondyloarthropathy,suchasankylosingspondylitis,SAPHOsyndromeandCRMO,thelattertwoconditionsbeingcharacterisedbythecombinationofosteitisandhyperostosis,whilemetabolicconditionsincludePaget’sdisease.IncaseswherethediagnosiscannotbemadeonMRIalone,CTisoftenveryhelpful.

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Educationalaims:• Toillustratetheimagingfeaturesofthemorecommonnon-neoplastic

vertebrallesions,sothataccuratediagnosisbasedpurelyonimagingcanprecludetherequirementforneedlebiopsy

Degenerative disordersDr Thillainayagam Muthukumar

Thistalkwilldescribethepathoanatomicprocessesoccurringinspinaldegenerativedisease.Imagingmodalitiesusedinevaluationofdegenerativeprocesseswillbediscussed.

Seronegative spondyloarthropathiesDr Marianna Thomas

Spineimagingisperformedaspartoftheinitialassessmentforclinicallysuspectedaxialspondyloarthropathy,althoughitdoesnotcounttowardsthewidelyusedASASdiagnosticcriteria.TheimagingarmofthesecriteriarequirethepresenceofradiographicsacroiliitisaccordingtothemodifiedNewYorkcriteriaorevidenceofsacroiliacjointinflammationonMRI,inadditiontothetypicalclinicalfeatures.

RadiographicandMRIfindingsinthespineandsacroiliacjointsarepresented,andtheutilityofthesefindingsforthediagnosisofspondyloarthropathydiscussed.Inaddition,examplesofdifferentialdiagnosesareshown.Theroleofimaginginfurthermanagementoftheseronegativespondyloarthropathies,complicationsoftheconditionandsometechnicalaspectsofimagingwillalsobedescribed.

EducationalAims:• Tounderstandtheroleofimaginginthediagnosisandmanagementof

seronegativespondyloarthropathies• Torecognisetheimagingfeaturesofthediseaseanditscomplications• TogainknowledgeofstandardMRIprotocolsofthespineandsacroiliac

joints

Learningobjectives:• Toidentifyfeaturesofseronegativespondyloarthropathyonradiographs

andMRIofthespineandsacroiliacjoints,andprovideanassessmentoftheprobabilityofthediagnosis

• Todistinguishimagingfeaturesofaxialspondyloarthropathyfromthecommondifferentialdiagnosis

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DISH, OPLL and other ossific/calcific conditions in the spineProfessor Filip Vanhoenacker

DISH,spondylosisandosteochondrosisofthespinearecommonincidentalfindingsonimaging,oftenseeninmiddle-agedandelderlypatients.CPPDandHADD(pseudogout)aboutthespinearealsorelativelycommon,butarerarelysymptomatic(e.g.crowneddenssyndromeandcalcificationofthem.longuscolli).

OPPLtypicallyaffectsthecervicalspineandismorecommoninAsianpeoplethaninEurope.

Syndesmophytesarethehallmarkoflongstandinginflammatorydiseaseofthespine.

SAPHOtypicallyaffectsthespineandthesternoclavicularjoints.

Othermetabolicdisordersassociatedwithcalcificationsorossificationsinthespinearefluorosis,acromegaly,haemochromatosis,hypoparathyroidism,ochronosis,hypophosphatemicosteomalaciaandrarelyPaget’sdisease.

Anycauseofspinalankylosismaypredisposetounstablespinalfractures,whichareoftendifficulttoassessonconventionalradiographs.Evenminortraumamaycausesevereneurologicaldeficitinthosepatients.AlthoughCTisexcellenttoevaluatetheextentofthefracture,MRIisoftenneededtoevaluatethespinalcord.

Learningobjectives:• Todiscussthedifferentialdiagnosisofcalcificationsandossificationsinthe

spine• Todiscusstheclinicalsignificanceoftheseimagingfindings

Spinal tumoursDr Asif Saifuddin

Vertebraltumourscanbeeitherbenignormalignant,thelatterbeingeitherprimaryormorecommonlymetastatic.Theycommonlyproducespinalpainwithorwithoutneurologicaldeficit,andhaveawideageofpresentation.

Vertebralhaemangiomaisthecommonestbenigntumour,typicallyfoundincidentallyonspinalMRI,andthevastmajorityareeasilycharacterisedduetotheirfattySI.Otherprimarybenigntumoursusuallypresentinchildrenandareacommoncauseofpainfulscoliosis,whichcanbereactiveorstructural.Osteoidosteomaandosteoblastomapresentwithreactivescoliosisandparaspinaltenderness,thelesiontypicallylocatedintheneuralarchontheconcavesideattheapexofthecurve.Spinalaneurysmalbonecystscanpreferentiallyinvolveonesideofthevertebralbodyresultinginasymmetricalcollapseandastructuralcurve,thelesioncommonlycontainingmultiplefluidlevels.Themajorityofbenignvertebraltumoursareadequatelycharacterisedbyimaginganddonotrequire

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diagnosticneedlebiopsy.

Malignanttumourstypicallyaffectthevertebralbodyandmayproducepathologicalcollapsewiththepotentialforcordcompression,usuallyinadults.

Thecommonestlesionsaremetastases,plasmacytoma/myelomaandlymphomaandtheyhavefewcharacterisingfeatures.Therefore,apatientpresentingwithsinglelevelpathologicalmarrowinfiltration,with/withoutcollapsewilllikelyrequirediagnosticneedlebiopsy.

Educationalaims:• Toillustratetheimagingfeaturesofthecommonerbenignandmalignant

vertebraltumours• Toindicatewhichcanbeconfidentlydiagnosedbyimagingalonewithoutthe

requirementforneedlebiopsy

Vertebroplasty: where are we now?Dr Damien Taylor

Thispresentationwillprovideanoverviewofthepathophysiologyofspinalfracturesandtheroleofvertebroplasty,kyphoplastyandsacroplastyinmodernpractice.

Cervical spine traumaDr Prudencia Tyrrell

Injurytothecervicalspineaccountsforapproximately33%ofallspinalinjuriesbuttheriskofneurologicaldamageinthecervicalregionissignificantlyhigherthaninotherareasofthespine.Cervicalcordinjuryhasdevastatingconsequencesforthepatientandtheirfamily.Despitetheadvancesinimaging,theinitialclinicalassessment–historyandexamination–remainsparamountindirectingthefurtherimagingcourse.

Thescopeofthistalkwillcovermissedinjuriesandwhytheystillhappen.Theroleofradiographsandcross-sectionalimagingisdiscussed,togetherwithanumberofcasebasedscenariosillustratingthevalueandadditionalinformationthatcanbeprovided.Despitecomputedtomography(CT)havingbecometheinitialimagingmodalityofchoiceintheacutehighimpactinjury,plainradiographsarestillemployedandknowledgeoftheapproachtointerpretationremainsimportant.

Someclinicalsituationswhereinterpretationmaybedifficultrequirespecialmentionincludingtheelderly,theadolescentandthepatientwitharigidspine.Thiswillbediscussedinmoredetail.

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Thoracolumbar spine traumaDr Tuhin Sikdar

Theincidenceofspinaltraumacontinuestorisewithresultantincreaseinthecostofhealthcareprovisionfortreatmentandrehabilitation.Recognitionoftheinjurypatterniscrucialinachievingamorecomprehensiveunderstandingandassessmentofthoracolumbarspinalinjury.Manyclassificationsystemsexistandrangefromtoosimplistictooverlycomplex.TheDenisclassificationisonethatiswidelyusedandisbasedonplainradiographicappearances.Therearehoweverdistinctpatternsofinjurythatexistandrecognitionofthispatternhelpsinpredictionofthefullextentofinjury.

Theroleofimagingwillbediscussedinthispresentation.Conventionalradiographyremainstheinitialscreeningmethodinmostcentres.WithincreasinguseofspiralCT,thereislessrelianceonplainradiographsinassessmentofthepolytraumapatient.

MultidetectorrowCThelpsinassessmentofthoracicandabdominalorgansbesidesprovidingspinalevaluation.ThehighresolutionofCTwithabilitytomultiplanarreconstructiongivesabetterunderstandingoftheseinjuries,helpsassessspinalstabilityandguidepatientmanagement.MRremainstheimagingmodalityofchoicefordirectimagingofthespinalcordandisbestplacedtoassesstheextentofsofttissueinjury.Itprovidesinformationonthenatureandextentofspinalcanalcompromise,helpsensurerationalapproachtothesurgicalmanagementoffractureandmaybeusedtopredictoutcome.

Spinal intervention: how I do itDr Damien Taylor

Thispresentationwillprovideanoverviewofspinalinterventiontechniques,withparticularemphasisonvertebralbiopsyforinfection.Therewillalsobeadiscussionoflesscommonpracticalpainreliefprocedures.

The post-operative spineDr Prudencia Tyrrell

Spinalsurgeryismostfrequentlyperformedtodecompress(discherniation,stenosis,malignantinfiltration),tofuseandstabilise(particularlyfollowingtraumaorinfiltrativedestructiveprocesses)andtocorrectdeformity.Oftentheremaybeacombinationoftheseproceduresatoneoperation.Surgicalinstrumentationorbonegraftaresometimesemployed.

Patientspresentingwithsymptomspostoperativelymaybeearlyorlaterelativetotheprocedureandinturnsymptomsmayrelatetothesurgicalprocedureitselforbecompletelyunrelatedtothesurgery.Anumberofpost-operativecomplicationsarediscussedandimagesshowntotryandillustrateboththenormalandabnormalpost-operativefindingsinthespine.

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FORTHCOMING EVENTS

CONTRAST STUDY DAY AND ESSENTIAL PHYSICS FOR FRCR29 - 30 JANUARY 2015

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11 MAY 2015LONDON

THORACIC IMAGING15 MAY 2015CAMBRIDGE

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EMERGENCY OUT OF HOURS RADIOLOGY20 MAY 2015

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