Spine radiography

Role and limitations of the method

Spondylography is a classical radiological examination. It is routinely performed in two projections: anteroposterior and lateral (additional specialized patient positions are used less frequently). The main and most significant disadvantage of classical radiography is the complete impossibility of visualizing and adequately assessing the state of neural structures. The physician cannot see the brain or spinal cord, nor the elements of the peripheral nervous system, on the image.

For this reason, the method is used extremely rarely in modern neurology. It has been almost completely replaced by X-ray computed tomography (CT) and magnetic resonance imaging (MRI). It is important to emphasize that even for a detailed assessment of specific lesions exclusively affecting the bony structures of the spinal column and skull, modern CT is a significantly more informative tool than a conventional X-ray.

Main indications for spondylography

Despite its limitations, spondylography retains its niche in initial diagnostic evaluations. The key indications for the study are:

• Traumatic injuries. Primarily, the method aims at the rapid diagnosis of vertebral fractures.
• Intervertebral disc herniation. It is impossible to directly visualize a herniation, but the physician can identify its indirect radiological signs on the image.
• Osteoporosis. Assessment of the general bone tissue structure.
• Neoplastic processes. Detection of both primary spinal tumors and secondary (metastatic) lesions of bony structures.
• Infectious diseases. Diagnosis of infectious lesions of the vertebral bodies (spondylitis).
• Joint pathology. Assessment of changes in the zygapophyseal joints of the spinal column (spondyloarthritis).

Diagnosis of ligamentous apparatus injuries

Diagnosing ligament injuries requires an integrated approach, as the altered ligaments themselves are completely invisible on standard radiographs. Conventional spondylography is strictly mandatory in this case, but its purpose is solely to exclude bone trauma (fractures).

For specific diagnosis, a local anesthesia test is used, aimed at temporarily relieving the pain syndrome. 3–5 ml of a 2% novocaine solution is injected into the interspinous space. If the pain temporarily disappears (positive test), this directly indicates a rupture of the interspinous ligaments. If the pain persists (negative test), it does not rule out the presence of a rupture. Pain in such a situation may be sustained by concomitant degenerative processes in the intervertebral discs.

In addition to clinical tests, radiological methods are also used:

1. Ligamentography. This is a specialized contrast study. An aqueous contrast solution is injected on both sides of the spinous processes. If there are defects or tears in the interspinous ligaments, the contrast agent flows into them. On an anteroposterior projection image, such accumulations will be visible as shadows against the light contours of the ligaments.
2. MRI. It is the most informative method for visualizing ligaments.

Principles of treatment for ligament tears

Approaches to treating ligamentous injuries depend on the time elapsed since the injury. In the early stages, conservative functional treatment is indicated. Upon admission, the patient undergoes anesthesia of the injured area, which is then repeated at intervals of 3–4 days. Strict bed rest is mandatory: the patient is placed supine on a firm bed equipped with a special board. The total duration of this regime is from 3 to 6 weeks.

Rehabilitation measures begin as early as possible. From the very first days, gentle physical therapy exercises (PT) are prescribed. Starting from the second week, the patient is allowed to carefully turn onto their abdomen, and back massage is added to the treatment course.

The optimal method of conservative therapy is considered to be the use of an extension brace. Its design allows the spinous processes of the vertebrae to be brought as close together as possible, and thus the torn ligaments attached to them. Immobilization in the brace is maintained for the entire treatment period (4–6 weeks). The patient continues physical therapy and physiotherapy procedures directly while wearing the brace.

In later stages, conservative methods prove to be ineffective. Surgical treatment (operative plastic surgery of the interspinous ligaments) is strictly indicated in cases where recovery cannot be achieved conservatively within one year after the rupture occurs.

Complicated spinal injuries

In peacetime, spinal cord injuries account for 0.7% to 2% of all types of traumatic injuries. At the same time, mortality rates remain catastrophically high: 50% to 90% of victims die at the prehospital stage or in the hospital (predominantly in cervical spine injuries).

The spinal segments are distributed by frequency of injury as follows:

• The cervical spine is injured in 6–9% of cases (typical mechanism: "diver's trauma" in shallow water).
• The thoracic spine is affected in 42–45% of situations.
• The lumbar spine is injured most frequently — in 46–50% of cases.

For the thoracic and lumbar spine, typical mechanisms include falls from a height, as well as industrial and vehicular accidents. The pathomorphological picture of closed spinal trauma varies. The degree of injury to the spinal cord and cauda equina roots ranges from microscopic changes to severe contusions, lacerations, and anatomical transection. Spinal cord edema develops rapidly and can reach such a degree that the neural tissue completely fills the entire lumen of the spinal canal.

Class and exam questions

What else to study on this topic

• Methodology of ligamentography
• Principles of applying an extension brace
• Surgical repair of interspinous ligaments
• Pathophysiology of spinal cord edema in closed trauma
• Radiological signs of spondylitis and spondyloarthritis

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.