Back and Spine

Clinical Morphology 2019, Imaging Workshop

Dr. Jon Hallstrom
 Objectives
• Identify the main osseous components of the spine on radiographs, CT, and MRI

• Identify the intervertebral disc on CT and MRI, and the spinal cord on MRI

• Identify spinal levels on radiographs, CT, and MRI on fontal/coronal or

lateral/sagittal views
 Tips to identify major osseous components
• Cervical • Thoracic and Lumbar
• From front to back on sagittal/lateral, axial
• Vertebral body
• Neural arch
• Transverse process, right and left
• Pedicle, right and left
• Facet (superior and inferior articulating
process), right and left
• Lamina, right and left
• Spinous process
• From front to back on sagittal/lateral, axial
• Vertebral body
• Neural arch
• Pedicle, right and left
• Transverse process, right and left
• Facet (superior and inferior articulating process),
right and left
• Lamina, right and left
• Spinous process

• From side to side on coronal/frontal, axial

• Most lateral structure right and left is the transverse process
 Tips to identify spinal region
• Regional anatomy
• Cervical-head and upper chest
• Thoracic-heart and lungs
• Lumbar-kidneys and bowel

• Sagittal alignment
• Cervical lordosis
• Thoracic kyphosis
• Lumbar lordosis

• Vertebral body and neural arch, ribs

• Cervical transverse processes arise from vertebral body and contain transverse foramen
• Thoracic ribs arise from body and transverse process costal facets
• Lumbar vertebral bodies are larger and lack above
 Tips to identify spinal segment
• Cervical (7 segments)
• Count down from occiput on lateral or sagittal view
• Anteriorly: C1 arch anterior to dens, C2 vertebral body, …
• Posteriorly: C1 posterior arch, C2 spinous process, …
• Count up from first set of ribs on frontal or coronal view
• First ribs at T1, C7 vertebral body, …

• Thoracic (12 segments)

• Count ribs on frontal or coronal view

• Lumbar (5 segments)
• Count down from last set of ribs on frontal or coronal view
• Last set of ribs at T12, L1 vertebral body, …
• Count up from last fully formed intervertebral disc space on lateral or sagittal view
• Last fully formed disc space at L5-S1, L5 vertebral body, …
 Tips to differentiate imaging
• Radiographs
• Think bones
• Frontal and lateral views
• Bones are dense or white

• CT
• Think radiographs on cross-fit
• Multiple planes, including axial
• Bones are dense or white
• Fat is dark

• MR
• Think more than bones, e.g. intervertebral discs, spinal cord
• Multiple planes, including axial
• Bones are variable
• Fat is bright
• T1-weighted images = dark fluid
• T2-weighted images = bright fluid
Cervical
Thoracic
Lumbar
Cervical spinal cord

Conus Medullaris
Cauda equina
Cervical Frontal Lateral
Cervical
Frontal Lateral

Spinous process often described as a Structures are “superimposed” on 2D

midline “tear-drop” structure on radiographs, such that cervical
frontal/coronal view transverse processes “project” over
the vertebral body on lateral view
Thoracic Frontal Lateral
Thoracic

Frontal Lateral

I like to think of an “animal face” for frontal/coronal

views of the thoracic and lumber spine, where vertebral
body is the head, pedicles the eyes, transverse procresses
the ears, spinous process the nose (and disc space the
mouth)
 Frontal Lateral
Lumbar
Lumbar
Frontal Lateral
 Axial Coronal Sagittal

Cervical CT

Transverse
Foramen
Spinous process

Lamina
Lumbar CT

Coronal Pedicles
(front to Vertebral body
back) Inferior
facet/articulating
process

Axial
(superior to Transverse
inferior) process

Spinous process
Lumbar MRI
Sagittal T2-weighted Sagittal T1-weighted Axial T2-weighted

L1 spinous process

Conus medullaris

L3 vertebral body Transverse process

Cauda Equina

L5-S1 disc space

 Spinal cord
Neural Foramen

Sagittal T2-
weighted
Thoracic MRI

Facet joint

Axial T1-
weighted
Lumbar MRI
 Session Cases
• What is the imaging modality?
• Radiograph, CT, MRI

• Identify labeled anatomy-arrow annotations

• Structure
• Side
• Level (unless specified)

• Contemplate what imaging finding is shown-circle annotation

Magnification of upper
middle image
No level required
Obtained at level of line
through left image
Midline Left of midline