back to basics part ii: more soft tissue stuff
TRANSCRIPT
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Back to Basics Part II: More Soft
Tissue Stuff
Jennifer Pedley, MS, DC, CCSP, DACBR
Chiropractic Radiologist
www.jprad.com
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Search Pattern
• Cervical Spine
• Thoracic spine
• Lumbar spine
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Search Pattern for Cervical Spine
• Search pattern other than osseous of cervical
spine:
– Right and left carotid arteries
– Stylohyoid ligament (ossification)
– Posterior and anterior longitudinal ligament
– Prevertebral soft tissues
– Tracheal air shadow
– Upper lung fields
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Here we go!
• Case study approach
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Case 1: Cervical Spine
• 43 year-old male, neck pain.
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• Right tracheal
deviation
• Normal thyroid
cartilage
calcification
R
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Deviation of the tracheal air shadow-
QUIZ #12
• Differential Diagnosis: (QUIZ #12)
– Lymphoma
– Teratoma
– Goiter
– Tumors of thymus or thyroid
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Follow-up
• Chest radiographs: PA and lateral with full
inspiratory effort
• CT imaging of the chest
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Case 2: Cervical Spine
• 85 year-old female chronic neck pain
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Calcification within the right and left
lateral soft tissues of cervical spine
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Diagnosis
• Atherosclerosis of the right and left carotid
arteries.
– In the lateral soft tissues, at the level of C3, C4.
• Contraindication for soft tissue
work/massage; treatment of ultrasound.
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Follow-up
• Doppler ultrasound
• Referral to primary care physician
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Case 3: Cervical Spine
• 35 year-old female with neck pain. No
trauma.
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Lateral cervical spine
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Findings/Diagnosis
• Calcification of the stylohyoid ligament
• May be symptomatic
– Clinically correlate for Eagle’s Syndrome
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Eagle’s Syndrome
• Symptoms: sharp nerve-like pain in the jaw or back
of the throat, or ringing or buzzing of the ears
(tinnitus) increased with moving jaw, swallowing or
the cervical spine rotation.
– May come in contact with the internal carotid artery
• Cause: idiopathic
• Treatment: If symptomatic, surgical resection.
– Regrowth are common
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Case 4: Cervical Spine
Male with neck pain.
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www.auntannie.com
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www.eurorad.org
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Findings
• Ossification of the anterior longitudinal
ligament.
• Ossification of the posterior longitudinal
ligament.
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Diagnosis-
• Diffuse Idiopathic Skeletal Hyperostosis
(DISH)
• Complications: compress the esophagus with
difficulty swallowing, and spinal cord
stenosis.
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Case 5: Cervical Spine
• 73 year-old male neck pain following a motor
vehicle accident.
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Lateral radiograph
www.koreamed.org
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Findings
• Retropharyngeal soft tissue widening
– 29.0 mm
• Retrotracheal soft tissue widening
– 53.0 mm
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Widening of prevertebral soft tissues
• Retropharyngeal soft tissue: Normal= at C2 level is 7 mm
• Retrotracheal soft tissue:
Normal= at C6 and C7 level is 22 mm
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Diagnosis/Cause
• Edema or hemorrhage resulted in widening of
the prevertebral soft tissues following the
motor vehicle accident.
• Complication: compressing the esophagus
and displacing the trachea
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Follow-up imaging
• MRI (without contrast)
– Identify soft tissue swelling/edema
– Evaluate the remaining soft tissues such as disc,
posterior soft tissues, spinal cord and neural
elements.
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Other differentials
• Other differential diagnosis for widening of
the prevertebral soft tissues (nontrauma):
– Infection
– Tumor of the thyroid gland
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Case 6: Cervical Spine
• 55 year-old female with neck pain following
motor vehicle accident
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AP and lateral
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Bilateral anterior oblique
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Radiopacity of right upper lung field
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Differential Diagnosis
• Pulmonary nodule
• Versus exostosis of the posterior 4th rib
• On a side note: There is a normal nuchal bone
within the posterior soft tissues.
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Follow-up
• Advanced imaging: CT imaging of the chest
will determine the location (lung vs. rib) of
the radiopacity
• Final diagnosis= unknown
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Case 7: Cervical spine
• Chronic neck pain
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Lateral cervical-QUIZ COMING
UP
www.3dmedicaleducation.co.uk
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Findings
• Continuous, thin ossification of the outer fibers of the annulus fibrosus.
• Fusion of the facet joints
• Normal nuchal bone within the posterior soft tissues.
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Diagnosis
• Ankylosing Spondylitis
• Thin ossification of the annulus fibrosus
– Inflammatory arthritis, seronegative rheumatoid factor; positive lab study of HLA-B27
– Favors the synovial joints such as the facet and sacroiliac joints.
• Differs from DISH which is thick, flowing ossification of the anterior longitudinal ligament.
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Search Pattern for Thoracic Spine
• Search pattern other than osseous of thoracic
spine:
– Lung fields/Chest
– Tracheal air shadow
– Vasculature
– Spinal soft tissues
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Case 1: Thoracic spine
• AP image not available
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Findings
• Cluster of radiopacities or calcifications
within the right mediastinum, at the level of
the aortic knob
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Differential diagnosis
• Calcified lymph nodes versus space
occupying lesion (tumor)
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Follow-up
• Need history and prior chest radiographs
• Chest radiographs: PA and lateral views with
full inspiratory effort.
• CT imaging
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Diagnosis
Patient was diagnosed with either calcified lymph
nodes versus granuloma due to previous old
infection. No tumor.
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Case 2: Thoracic spine
• The search pattern on the AP thoracic spine
should also include evaluating the chest
anatomy such as the tracheal air shadow.
• If there is abnormality seen within the chest
such as tracheal air shadow deviation, PA and
lateral chest radiographs should be performed
with full inspiratory effort.
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PA radiograph of the chest
www.researchgate.net
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Findings
• Large mass of the right paratracheal region with medistinal widening, and with left deviation of the tracheal air shadow.
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Follow-up
• CT imaging of chest
• Diagnosis: Tumor, adenocarcinoma of the
lung.
• Referral to primary physician
– Patient underwent chemotherapy
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Case 3: Thoracic spine
• Mild mid back pain
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AP and lateral thoracic spine
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• Curvilinear
calcification
within the aortic
knob
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Diagnosis
• Atherosclerosis of the aortic knob
• Degenerative disc disease of the thoracic
spine
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Case 4: Thoracic spine
• Chronic mid back pain
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Lateral Thoracic
www.researchgate.net
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Findings
• Thick flowing
anterior
ossification of the
anterior
longitudinal
ligament.
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Another patient-AP Thoracic
• Anterolateral ossification of the anterior longitudinal ligament, absent/less severity on the left side of the mid thoracic spine.
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Diagnosis
• Diffuse Idiopathic Skeletal Hyperostosis
(DISH)
• Avoids the left side of the mid thoracic spine
due to the descending thoracic aorta.
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Search Pattern of Lumbar Spine
• Search pattern other than osseous of lumbar spine:
– Liver
– Pancreas
– Adrenal Glands
– Kidneys
– Spleen
– Gallbladder
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Search Pattern of Lumbar Spine
• Search pattern other than osseous of lumbar spine:
– Bowel
– Vasculature
– Lower lung fields
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Case 1: Lumbar spine
• Female with chronic low back pain; previous
abdominal surgery (surgical clips)
• Patient is 60 years-old
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AP Lumbar
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Findings
• The liver extends further medially and
inferiorly than usual overlying the right iliac
crest
• Spleen and kidneys are of normal size.
• Multiple surgical clips and sutures of the
bowel (she still has an IUD---oops, probably
forgot).
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Another patient: 48 year-old female
with low back pain
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Findings/Diagnosis
• Enlarged liver= Hepatomegaly
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Hepatomegaly vs. Reidel’s Lobe of
the Liver
Hepatomegaly– Crosses the spine; rounded fullness of the inferior border
extending below the kidney
Reidel’s Lobe– Normal variant of the right lobe of the liver
– Tongue-like projection that can extend to the iliac crest
– Most commonly seen in females
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Differential Diagnosis of
Hepatomegaly (many more causes):
• Congestive heart failure
• Diabetes Mellitus
• Alcoholism
• Cirrhosis
• Tumor mets
• Hepatitis
• Medications
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Follow-up
• CT imaging
• Laboratory studies
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Case 2: Lumbar spine
• 55 year-old male; alcoholic; low back pain
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AP Lumbar
www.cnx.org
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• Speckled calcifications of the midabdomen,
from the left upper abdominal quadrant
crossing the spine.
• The calcifications reside within the head,
body and tail, pancreas
Findings & QUIZ
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Diagnosis
Pancreatic Calculi– Secondary to chronic pancreatitis- mc alcohol
abuse.
– Other causes:
• Gallstones- obstructing the entrance of the pancreatic
duct into the CBD.
• Hyperparathyroidism
• Cystic fibrosis
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Follow-up
– Diagnostic US
– CT of the Abdomen
– Endocrinologist
Brant W and Helm C. Fundamentals of Diagnostic Radiology, 3rd ed. 2007; 784-785.
Halpert R. Gastrointestinal Imaging, 3rd ed. The Requistes. 2006; 172.
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Case 3: Lumbar spine
• 45 year-old male with severe low back pain.
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AP Lumbar Spine
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Findings
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Findings
• Bilaterally small round radiopacities in the
right and left kidneys
• Always check in the path of the ureters and
the bladder for more stones.
– Ureters are anterior to the transverse processes.
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Diagnosis
Nephrolithiasis
Symptoms:
– Cramping pain of the low back, flank, groin or
abdomen
– Pain waxes and wanes; colicky
– Nausea, vomiting
– Fever
– Hematuria
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Follow-up
Follow-up
– Ultrasound then if necessary,
– CT of the abdomen with and without contrast
Treatment
– Medication for pain
– If obstruction, lithotripsy or surgical (nephrologist)
![Page 84: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/84.jpg)
Different patient
![Page 85: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/85.jpg)
Findings/Diagnosis
• Extensive calcification within the right kidney
• Diagnosis: Staghorn Calculus
![Page 86: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/86.jpg)
Staghorn Calculus- QUIZ
QUESTION
• Cause: recurrent infections; or renal tract
anomalies.
• Symptoms: fever, hematuria, flank pain, and
potential septicemia and abscess formation.
• Referral: Nephrologist
![Page 87: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/87.jpg)
Case 4: Lumbar spine
• 48 year-old female with chronic low back
pain for 9 months.
![Page 88: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/88.jpg)
![Page 89: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/89.jpg)
Note: metallic
clothing artifact
overlying the sacral
ala, due to eyelets of
sweatpants.
R
![Page 90: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/90.jpg)
Diagnosis
• Normal liver: Reidel’s lobe
• Enlargement of the spleen= Splenomegaly
![Page 91: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/91.jpg)
Follow-up for Splenomegaly
• CT of the abdomen with and without contrast
• Referral/Consultation: Internist/Oncology
![Page 92: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/92.jpg)
Diagnosis
• Lymphoma
– Resulting in enlargement of the spleen
![Page 93: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/93.jpg)
Differential Diagnosis of
Splenomegaly
• Malignancy- lymphoma; leukemia
• Bacterial Infection- TB; lyme disease
• Fungal Infection- Toxoplasmosis; histioplasmosis
• Viral- Epstein barr virus (mononucleosis)
• Sickle cell anemia
![Page 94: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/94.jpg)
Reidel’s Lobe of the Liver
• Normal variant of the right lobe of liver
• Most common in females
• Narrow tongue-like projection, extending
inferiorly and can extend to the iliac crest
• Never crosses the spine
![Page 95: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/95.jpg)
Case 5: Lumbar spine
• 42 year-old female with thoracolumbar spine
pain.
![Page 96: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/96.jpg)
AP and lateral views
![Page 97: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/97.jpg)
Radiopacity of right upper
abdominal quadrant
![Page 98: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/98.jpg)
Diagnosis
• Since the radiopacity is anterior to the spine,
the radiopacity is not within the kidney (and
not retroperitoneal in location)
– Anatomically, the kidneys are retroperitoneal in
location.
• Diagnosis: Gallstone (cholelithiasis)
![Page 99: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/99.jpg)
Follow-up
• Ultrasound
• Consult with abdominal surgeon
– Laproscopic, cholecystectomy (removal of
gallbladder).
![Page 100: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/100.jpg)
Cholelithiasis
• Most common 40 year-old female– younger patient with gallstone due to sickle cell anemia
• Symptoms: – Right upper quadrant pain, especially after a fatty meal
– Pain radiates between the shoulders or under the right shoulder
– Indigestion, bloating, nausea, and/or vomiting
• 10-15% radiopaque on xray; mostly made of cholesterol
![Page 101: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/101.jpg)
Different patient
• Patient has chronic gallbladder disease (next
slide)
![Page 102: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/102.jpg)
Calcification of the gallbladder wall
with multiple gallstones
www.mypacs.net
![Page 103: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/103.jpg)
“Porcelain Gallbladder”
• Adenocarcinoma of the gallbladder, due to
the calcified wall.
Follow-up
– Abdominal surgeon>> cholecystectomy
– Oncology
![Page 104: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/104.jpg)
Case 6: Lumbar spine
• 52 year-old male with low back pain and
abdominal pain.
![Page 105: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/105.jpg)
AP Lumbar
www.mypacs.net
![Page 106: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/106.jpg)
Normal Bowel gas
• Small bowel gas should be centered over the
spine on the AP lumbar radiograph.
• Large bowel gas will be located in the outer
perimeter of the abdomen with ascending,
transverse and descending colon.
![Page 107: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/107.jpg)
Findings
• Small bowel
gas is being
displaced to
the right.
R
![Page 108: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/108.jpg)
Follow-up
• CT imaging (not available for this patient)
• Barium study was performed
![Page 109: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/109.jpg)
Barium study of the small bowel
www.mypacs.net
The barium
study
outlines the
small bowel
nicely but
likely a
mass of the
abdomen is
pushing the
bowel to the
right.
![Page 110: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/110.jpg)
CT confirmed mass
• Referral: Abdominal surgeon; oncologist
• End diagnosis: Retroperitoneal liposarcoma
– A mass was compressing and displacing the small
bowel to the right side of the abdomen.
![Page 111: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/111.jpg)
Case 7: Lumbar spine
• 68 year-old male with low back pain. The
pain began 4 weeks ago.
![Page 112: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/112.jpg)
AP and Lateral Views
www.mypacs.net
![Page 113: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/113.jpg)
Lateral Spot view of the Lumbar
Spine
www.mypacs.net
![Page 114: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/114.jpg)
Findings
• Compression fracture at L1 (patient forgot
that they had trauma a few weeks ago).
• Atherosclerosis of the abdominal aorta
– Widening the abdominal aorta of 3.5 cm
• Normal diameter is 2.0 cm
– Seen best on the lateral spot radiograph for this
particular patient.
![Page 115: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/115.jpg)
Diagnosis
• Aneurysm of the abdominal aorta at the level of L3
• Suspected aneurysm at the level of L2
![Page 116: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/116.jpg)
Follow-up
• Ultrasound
• MRI was performed as well to evaluate the
fracture of L1.
– The abdominal aorta was measured as well on
MRI axial images to be 4.6 cm
– Normal abdominal aorta= 2.0 cm in diameter.
![Page 117: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/117.jpg)
T2 Weighted Images of the Lumbar
Spine
www.mypacs.net
![Page 118: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/118.jpg)
Case 8: Lumbar spine
• Chronic low back pain
![Page 119: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/119.jpg)
![Page 120: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/120.jpg)
Findings/Diagnosis
• Thick, flowing ossification of the anterior
longitudinal ligament.
• Diagnosis: DISH
![Page 121: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/121.jpg)
Case 9: Lumbar spine
• This came across my desk the other day….
• On the AP and lateral radiographs of the
lumbar spine, the search pattern should also
include the lower lung fields to check for any
space occupying lesion(s).
![Page 122: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/122.jpg)
Nodule in the Right lower lung
![Page 123: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/123.jpg)
Nodule in the Right lower lung
![Page 124: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/124.jpg)
Follow-up
• CT of chest
![Page 125: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/125.jpg)
Search Pattern for Pelvis
• Search pattern other than osseous of pelvis:
– Bladder/Prostate/Uterus
– Vasculature
– Vas deferens
– Musculature/lateral soft tissues
![Page 126: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/126.jpg)
Case 1: Pelvis
• 43 year-old female with low back and pelvic
pain.
• History of cervical cancer; surgical resection
and chemotherapy one year ago.
![Page 127: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/127.jpg)
AP Lumbar
![Page 128: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/128.jpg)
Findings
• Large calcific mass within the pelvic basin on
the left with well-defined margins.
• Two surgical clips within the pelvic basin,
correlates with prior history.
![Page 129: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/129.jpg)
Diagnosis & Follow-up
• Uterine fibroid
• If you are still unsure of the mass, referral to
gynecologist and ultrasound of the pelvis are
recommended.
![Page 130: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/130.jpg)
Uterine Fibroid aka Uterine
Leiomyoma
• Benign tumor within the muscular tissue of the uterus
• Symptoms
– None; or pain back of the legs
– Heavy, prolonged periods
– Pelvic pain
– Constipation &/or bloating>>pressure on bowel
– Infertility; Miscarriage
![Page 131: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/131.jpg)
Uterine Fibroids
• Fibroids may shrink during menopause due to
decrease in estrogen levels
– Increase in size during pregnancy
![Page 132: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/132.jpg)
Case 2: Pelvis
• Male with back pain and difficulty urinating
![Page 133: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/133.jpg)
AP Pelvis
www.mypacs.net
![Page 134: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/134.jpg)
Findings
• Distended
bladder
![Page 135: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/135.jpg)
Differential diagnosis
• DDX for distended bladder:
– They had to pee and you did not let them pee
before taking the xray
– Prostate pathology/enlargement
![Page 136: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/136.jpg)
Follow-up
• Referral to Urologist
• Digital rectal examination
• Laboratory studies
• Transrectal ultrasound with biopsy
• MRI maybe performed: Differentiate between
benign prostatic hyperplasia and adenocarcinoma
![Page 137: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/137.jpg)
MRI: Axial Proton Density weighted
fat saturated images
www.mypacs.net
•Enlarged prostate
•Normal size=same size as
rectum
•Note: A normal prostate
should be approximately the
same size as the rectum on
the axial image.
![Page 138: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/138.jpg)
Coronal PD Weighted Fat Sat
Images
www.mypacs.net
•Enlarged
prostate
![Page 139: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/139.jpg)
Diagnosis of the Prostate
• Adenocarcinoma
• Symptoms:
– Fever, night sweats, chills & weight loss
– Pain, burning with urination
– Blood in urine
– Weak flow of urine; frequency
– Constant back, hip &/or pelvis pain
![Page 140: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/140.jpg)
Treatment (Prostate Cancer Institute & National Cancer Institute)
Surgical– Radical prostatectomy
– Robotic laparoscopic prostatectomy
• 5 small abdominal incisions
• Ex. Da Vinci Robotic Prostatectomy (Texas)-
www.video.google.com
![Page 141: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/141.jpg)
Treatment
• Radiation-brachytherapy (radiation seeds)
• Hormone therapy- decreased testosterone by
LHRH
• Chemotherapy
![Page 142: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/142.jpg)
Radiation Seed Implantation
• Multiple metallic
specks overlying
the symphysis
pubis are radiation
seeds within the
prostate.
– Normal: prostate
overlies the
symphysis pubis on
the AP view of the
pelvis www.emedicine.com
![Page 143: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/143.jpg)
Case 3: Pelvis
• Mild low back and bilateral hip pain.
![Page 144: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/144.jpg)
Pelvis
www.wjg.net
![Page 145: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/145.jpg)
Findings
• Vascular calcification of the bilateral iliac arteries (black arrows)
• Vascular calcification of the bilateral femoral arteries (white arrows)
![Page 146: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/146.jpg)
Diagnosis
• Atherosclerosis of the bilateral iliac and
femoral arteries.
• Patient is likely on hypertension medication
• Referral: primary physician if patient has not
discussed vascular disease with their primary
doctor.
![Page 147: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/147.jpg)
Case 4: Pelvis
• History: Mild low back pain.
![Page 148: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/148.jpg)
AP Lumbopelvic
![Page 149: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/149.jpg)
www.radiopaedia.org
![Page 150: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/150.jpg)
Findings
• Tubular calcification in a V-formation within
the central portion of the pelvic basin
![Page 151: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/151.jpg)
Diagnosis
• Calcification of the vas deferens
• Clinical Significance:
– Diabetes mellitus,
– Normal ageing,
– Or due to infection
![Page 152: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/152.jpg)
Case 5: Pelvis
• Young patient with spinal cord trauma several
months ago.
![Page 153: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/153.jpg)
AP Pelvis
![Page 154: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/154.jpg)
Findings
• Abnormal bone formation within the extra-
skeletal soft tissues surrounding the right hip.
![Page 155: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/155.jpg)
Diagnosis
• Heterotopic Ossification known as myositis
ossificans.
![Page 156: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/156.jpg)
Other Examples
![Page 157: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/157.jpg)
Follow-up
• Standard advanced imaging is triple phase bone scan
with Tc 99M MDP
– early detection early as two weeks after injury.
• Biopsy leads to false positive diagnosis of
osteosarcoma
• CT can detect calcifications within the soft tissue
earlier than xrays.
• MRI is not helpful
• MSK Ultrasound Imaging can be performed.
![Page 158: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/158.jpg)
Causes of Heterotopic Ossification
• Trauma to the spinal cord
• Blunt trauma
• Contusion or bruise to muscle
• Repetitive trauma or muscle strain
• Burn victims
• Post surgical changes of the same region
![Page 159: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/159.jpg)
Myositis Ossificans
• Calcification may show up 2-4 weeks after
trauma
• Most commonly the thigh.
![Page 160: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/160.jpg)
Treatment
• Light therapies that does not induce bleeding;
Treat the inflammation first.
• Surgical resection: It may reoccur.
• Radiation therapy with external beam, or non-
steroidal inflammatories
![Page 161: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/161.jpg)
Case 6: Pelvis
• Mild low back pain. Doctor performed AP
pelvis radiograph to further evaluate the left
hip, after identifying calcific mass on the left
on the AP radiograph of the lumbar spine.
![Page 162: Back to Basics Part II: More Soft Tissue Stuff](https://reader034.vdocuments.site/reader034/viewer/2022050104/626c855064525d4fb7208d7f/html5/thumbnails/162.jpg)
AP Pelvis
R
www.radiology.wisc.edu
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Findings
• Multilobulated, periarticular densely calcified
mass is overlying the left hip and hemipelvis.
• There are no osseous erosions.
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Diagnosis
• Tumoral Calcinosis
– Hereditary metabolic dysfunction of phosphate
regulation
– Most commonly painless; Underlying bone is
normal.
• Most common locations (in descending order
of frequency):
– hip (most common), shoulder, elbow, and foot
(least common).
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Other Examples
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Follow-up
• Family history
• CT and MRI
• Laboratory studies
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Other possible differentials
• Hyperparathyroidism
• Calcium pyrophate deposition disease (pseudogout)
• Dermatomyositis
• Myositis ossificans
• Hypervitaminosis D
• Calcinosis of chronic renal failure
• Synovial sarcoma
• Calcific tendinitis
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Referral for Advanced Imaging-
Don’t be Afraid
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Advanced Imaging: Evaluating
the soft tissue
• Abdomen/Pelvis: US>>>>>CT
• Spine: MR, evaluate the disc, spinal cord,
nerve roots, brain
• Brain: CT for acute bleed/trauma
• Chest: Xray>>>>CT
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Advanced Imaging: Evaluating
the soft tissue-continued
• Extremities: MR for ligaments, labrum,
menisci, cartilage, tendons and muscle
• Extremities: CT for fracture and dislocation
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Criteria for Ordering MRI
• Some indicators:
– Neurological deficit
– Radiculopathy with no response to 4 week treatment
– Spinal stenosis
– Spinal fracture
– Degenerative disc disease with no response to 4 week treatment
– Recurrent sx’s after spinal surgery
– Clinically: infection, cancer, metastatic disease
www.healthlink.com and www.aetna.com
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MRI
• Contrast for Spine
– Intravenous: Prior surgery; Tumor/mass and
Infection
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Magnetic Resonance Imaging
• Sequences
– T1- fat is bright
– T2- CSF, fluid is bright
– Proton Density
– Gradient Echo
– STIR
• Sagittal, Axial and Coronal
www.medifax.com
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Spinal Structures (Sagittal)
• Cord-conus medullaris
• Central canal
• Disc – signal, height and contour
• Vertebral bodies; Facet; Spinous processes
• Nerve roots and neural foramina
• Ligaments (ALL, PLL, interspinous, ligamentum flavum)
• Abdominal Aorta
www.medifax.com www.mypacs.net
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Spinal Structures (Axial)
• Nerve roots and neural foramina
• Cord/Thecal sac
• Disc contour
• Central canal
• Ligaments (ligamentum flavum)
• Epidural space
• Facet joints
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www.jprad.com
700 East Redlands Blvd, Redlands CA. 92373 909.353.9348 www.jprad.com
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Additional References
• Brant W, Helms C. Fundamentals of Diagnostic Radiology, 3rd ed. 2007.
• Karaman K, et al. Endovascular Stent Graft Treatment in a Patient with Splenic Artery Aneurysm. Diag Inter Radiology, 2005; 11:119-21.
• Pride Y, MD et al. Splenic Artery Aneurysm: An Endovascular Approach to Therapy. Vascular Disease Management, Sept 2007; 4(5).
• Mahaderan S, MD. Plain Film Diagnoses You Cannot Afford To Miss. Academic Emergency Medicine. June 2007; Vol.7, No.6
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Additional References
• Halpert R. Gastrointestinal Imaging, 3rd ed.
The Requistes. 2006; 172.
• www.uterine-fibroid.org
• World Journal of Nephrology; April 06, 2012;
1 (2): 43-53.
• www.learningradiology.com
• Fardon, et al. Disc Nomenclature; 2014.
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