Dr. Gillard lectures on How to Read Your Lumbar MRI

Hello, my name is Dr. Douglas Dillard. I am the owner, founder and editor of Chyo geek.com. Welcome back. I'm going to teach you in this video how to

read

your

MRIs and I'm going to put out a disclaimer right now. Never doubt

your

radiologist's opinion on these images. This is for educational purposes only and I am definitely not teaching you how to

read

for pathology. If you really want to delve into this material, check out my website KY geek.com. Click the MRI tab. and there you will find a lot of information on the subject.

This information is more for my coaching clients, to get them up to speed before our coaching session. Now we have a lot to cover, so let's move on to the best way to get through it. this material is through PowerPoint and I have created a PowerPoint specifically for this purpose so I'm going to hang my head and now I'm going to focus on my laptop and here we go let's do a super quick review now again you need to go to the first one part where I speak. about the normal

lumbar

spine and its anatomy because I'm going to assume you know a lot, but I'll go over it real quick here, of course, this is an anterior posterior view of the skeleton if we expand on that, the

lumbar

spine has five. lumbar vertebrae which are stacked on top of a giant triangular shaped bone called sacrum from the lateral view which is called sagittal view, this view by the way is a coronal view or a PDA view from the sagittal view we can see that we have a lordotic curve which is shape and we have the five lumbar vertebrae separated by invertebral discs now if we cut you from a PDA view you are standing and I saw you in half like a lumberjack falling from a tree and we look towards the Rings we can see the axial view and this is an uneven cut or a view of the disc the disc has two parts a pulsating nucleus that soft substance is held firmly in place by rings of collagen called Lam that form the annulus fibrosus the disc is wired for pain it has nocioceptive fiber that runs along the covering vertebral nerve that transmits the sensation of low back pain.

Approximately 40 to 60% of you suffer from chronic low back pain. This is why these nerve endings become irritated. There is also an outgoing nerve pathway here. outside the teal sac if this is the L4 disc this is the route of the L4 exit nerve this is the route of the L5 transverse nerve that is still inside the teal sac remember there is no spinal cord or lumbar spine there is only a teal sac where they hang the nerve roots In this, the cerebrospinal fluid, in fact, they often line up like airplanes on the runway getting ready to sprout and we'll see some good pictures of the sprouting here, so again, if that were the L4 disc, this is the nucleus , this gray is the ring.

We will never be able to see the nocioceptive fiber because it is microscopic, but we will be able to see the pieces of this protruding nerve root. This would be the L4 nerve root. This would be the L5 transverse nerve root. This structure will be the theal saac now here is an MRI this is a T2 weighted image but the most important thing is that we go over the components here this is the vertebral body remember that the vertebrae have two main pieces it has a vertebral body in the front this is the front this is the back and in the back it has a posterior arch in this particular view you cannot see the pedicles or the side of the bidding arch you can only see the spinous process which is here in yellow this space between the posterior arch and the posterior arch Sorry, between the anterior part of the posterior arch and the posterior part of the vertebral body, that is your central canal or your central spinal canal or your vertebral canal and that is important, it should be about 20 mm in size For a normal person, if it measures less than 13 mm, you have central stenosis.

I have a whole page on stenosis, so check it out if you're interested. The conus medullaris or the tip of the spinal cord is right here at the L1 level, which is normal. The actual end of the spinal cord right there now the weight bearing line is a green line, well it doesn't have to be green, it can be any color, but it is a line drawn from the center of the body of the vertebra, the you drop it perpendicularly downwards and it should fall through the tip of the S1 segment and this is normal biomechanics, if this line were to fall here then you have anterior weight bearing and your biomechanics are screwed which could lead to disc problems and even something called the Spond thesis, I think. that's all I wanted to say here you can also notice these little nerves showing transverse nerve roots that have deviated from the main bundle here look at these black shoelaces right here alright there's a naked view you can look at that without the lines now, this is a parasagittal view, so the other one was right through the center of his sagittal spine sagittally speaking, this is a very lateral cut, it's right through the invertebral frame and you can see all of this right here, which is in white. packed in fat, it's a T1 weighted image so it will show the fat quite white and then you can see the route of the L2 nerve outgoing here is the L3 nerve root outgoing, the L4 nerve root outgoing X now nerve root 5 now here there is an axial view Again for the anatomy, again I didn't go around the entire disc, but when you look at a cut at the level of the disc, you want to see this posture margin that I have drawn here in yellow in this cartoon, what is important is the size of these holes neural or inverted frame or IVF all of them are also known as between the pink here this channel these should be open and this also tells you that you are in an unlevel view the posterior AR arch looks like a wishbone here is the handle of the wishbone which is the spinous process, the wishbone arms are the lamina and then we have the inferior articular process and the superior articular process that sandwich the actual facet joint.

Remember that they come together to form this true diarthrodial joint. Approximately 30% of you are the cause of your chronic illness. The pain is facet syndrome because these have noio receptor fiber and it is not as common as disc problems, but it is quite common, especially in the elderly. Now in the crotch of the sling, for lack of a better term, is the teal sac and this patient has a big one, they come in all shapes and sizes, this is a T2 weighted image, we'll talk about that in a minute because you can see the white cerebrospinal fluid and you can see the transverse nerve roots lined up here, actually.

You can even see inside the transverse nerve pathway here from L5. You can see the motor and sensory component. The pars interarticularis is right here, just after the inferior articular process, and it's this region of the bone right here that breaks in people with spond loiasis and spond. listhesis now, this is not a level cut, now that you're flipping the scroll up through your images, you'll notice that here we have a solid block of bone, you don't see the neuropformment here, but that means that Actually, this is a cut through the upper portion of the vertebral body right through the pedicle, so we can see the pedicle here, here is the pedicle, the articular pillars are here, superior articular process, inferior articular process, lamina, lamina and these Structures simply repeat and form. the spinal canal here or the central canal or the vertebral canal here is the teal sac you can clearly tell that the transverse processes are sticking out here you can see them and remember when we look at a CT scan or an MRI the images are inverted so that this is the left side this is the right side this is the front and this is the back now the level view of the L5 disk is a little strange so this is the L5 disk it is definitely an uneven cut on the right because we can see the neurop foramen here you can see the fat inside this T1 weighted image and here is the neurological framework outlined in green.

What is this point here? What is that structure? What is that structure? I'll give you a hint that it's one of the nerve roots. Let the five disks be L5. coming out of the nerve path and it's not being pinched or compressed by anything now here's the teal sac now this one is small right, we just saw a big one this one is small and this is what Mickey Mouse looks like this is Mickey Mouse's head , which is the theal bag and then the two Mickey Mouse ears, what do you think are good? Those are the transverse roots that have already sprouted from the theal saac, usually at L1 L2 L3 and often at L4, these will not be visible in an uneven cut.

They will still be inside the teal bag, but in L5 probably 85% of the time, maybe 95% of the time, at some point you will see them already outside the teal bag and, personally, I think that's why we have so many problems in the The L5 disc is symptomatic because these nerve roots are now exposed, they are more vulnerable, they are not surrounded by cerebrospinal fluid, there is a little bit inside this Dural container, but there is not as much inside the teal sac, so I think we are a little more vulnerable and it is a fact that 80-85% of all herniated discs occur at L5 or L4, so this would be a great study, it has never been done.

Here are the facet joints. A nice wide view of the facet joints. and I think that's all I needed to say about it. Now let's talk about T1-weighted versus T2-weighted images. Image of a T2 image. ​​I won't go into the physics and how it works, but the technology will accentuate high water content fabric. turns bright white or hyperintense is the official term, so Spano seros fluid is largely made up of water, which is why it glows white on the t2 image, so always look at the theal sac to see what kind of image have, why is it so important?

If you are evaluating disc degeneration, you should use the t2 weighted image, because remember the disc has a high water content, the nucleus is 80% water in a young healthy disc, so let's take a look at this herb T2, here's a normal one. The man is 40 years old. This is a normal looking disc. He has a pretty white appearance. These are pretty white. They're not as pretty, but they're still pretty pretty. But this disc is black, so it is called degenerative disc disease. It's not serious. the disc space has not collapsed if this disc space was thin, that is bad, it is a more serious type of degeneration, but remember I said that when disc degeneration occurs, the disc is susceptible to tearing and even bulges can form and here we have a small contained disk coming out of the back of this T2-weighted image. ​​This is also a midsagittal cut or it is a parasagittal cut.

It's right in the middle. Look at the C Ain it's thick. Here we have a good dimension that we can see. the spinous process, so this is a mid sagittal view, okay, let's move on to this now we immediately look at the teal sac and we see that it is black and this is what a T1-weighted image looks like, as if the tissues with high water content They become hypointense or black. So it's good because it differentiates the teal sac from the epidural fat, so the other property of T1 images is that it makes the fat a very white color, so we can get a good view of the teal sac from From now.

We can now observe these discs for degeneration. because this is a T1 weighted image they will all look black, here is the axio view, is this a T2 weighted or T1 weighted image? Very good, the teal sac is black, this is a large teal sac again, so this is a T1 weighted axio view. Is it a disc level cut? Yes, it is a cut at the disk level. Because? Because we can see the epidural fat right here and so we know we're under the pedicles in the and we can see the neuroforamen, so it should be T2 weighted and you can actually see the nerve roots lined up, the roots transverse nerves are aligned.

You can even see a little bit of snow liquid here, so here's an example of a sagittal slice and this is our mid sagittal view again, this is right in the center. If a samurai warrior was standing in front of you and he cut you to the top of your head and the blade went through your nose and chin, down your sternum to your navel, you would fall in half, this is what you would see. now in the middle, if we make one or two cuts, we can see that the central canal is thinner, so this is a parasagittal cut here and it accentuates the discernment.

It's actually a right parasagittal slice, so this guy had a right paracentral insight and if you go over a couple more slices and then you can see the neural foramen with that black dot, what is that black dot over there, that it's the protruding nerve root again, and you can even see the facet joints here, okay, that's the concept of cutting now, cutting axio. the cut is the same way if we start from the bottom, if we scroll down and get to the last cut, it will look like this, this is your S1, the top of your S1, now you can see Mickey Mouse, there is the theal sack there's the S1 going through the nerve roots that are well outside, they've been out for a long time, but if we go up a slice now we have an uneven slice, we just went through the disc,you can see the neural framework here and here what Would it be good if it was the exiting L5 nerve route to the right or to the left?

That's the right. Remember that these pictures are inverted and now you can see Mickey Mouse, but look, this really looks like Mickey Mouse. Now the nerve roots are just beginning to sprout. They are not completely, but they are almost expelled from the teal sac and you can see how they take the Duram Mater with them and form the nerve root sheath. If we upload another cut, now there is no more album, this guy was degenerate, right? Well we can't quite tell this is a T1 weighted but I know it was degenerated but you can see the darker disc material here if you go up a slice now it's lighter this is the vertebral body and this is anything that's hanging down about this. disc balls or herniation, but you can actually see the exit nerve roots very well here, all five roots, so if you want to see the L5 roots, especially the dorsal root ganglia, go up one slice above the dis level if We upload another one, probably two cuts higher.

Are we already at a dis level? No, you can't see the Fram neuropa and actually see the pedicle. this is the pedicle of L5 this is a superior articular process inferior articular process facet joint the lamina would be here here is the spinous process so that's the concept of splicing now let's have a little fun let's take a look at some pictures so what do you see? here first of all is it an axial image or Sagal good is it a sagittal image is it T1 weighted or T2 weighted good is it a T2 weighted image and let's look at the back of the disc it would be here on the right this is the front this is the back, this is definitely a mid sagittal cut, you can't see the diameter, it looks very good here, the central canal, this China is thick and together we now look at the back of the disc for pathology or bulges, immediately You can see what that is.

The 5 4 3 L2 disc has a large bulge coming out of the back, so the diameter of the canal is 20 mm, so it is a 8 8 mm 6 to 8 mm disc bulge, Is it a bump or is it a lump? Can we say from this image that no? We have to see the other slices or we have to see the axial view to get the morphology of the disc. You see anything else here. Okay, there's a little spike node, a little indentation right there. It doesn't mean much, it could be a trauma that happened a long time ago, it doesn't seem traumatic, so it's just a weakness in the endplate here, what's this little bubble here, right there, where my mouse is?

Ok that could be a sign of an annular tear, it's called a hi sign, technically it's not a full hello because it's not as white as the cerebrospinal fluid, but it looks like it could be a healing annular tear, now let's get to the t2 disc , let's take a look at the axial view, it's a cut at the level of the disc, absolutely look at these big channels here, that's a good thing, so we look at the outline of the disc and we immediately see that there is a big bulge sticking out of the disc, about 10 mm. would be around here, so it's probably a six, let's call it 5 to 6 mm, which is probably actually a 4 to 5 mm disc protrusion and I have a YouTube video that talks about the different types of discernment that I'll get.

I won't repeat that here but I'll put a link below or I'll go to my channel or I'll go to Kyo geek.com and you can find links to those okay let's look at another one okay here's another type is it very axial or sagittal ? Well, it's a T1-weighted or T2-weighted sagittal image, good t 28, it's very bright. I have very high intensity in this. Okay, there's the disk. Is this a young guy or an old guy? He's probably very young. He actually he is a professional. He was a basketball player from Europe and he was 23 or 24 years old, so these pucks look beautiful.

What's up with this album? Okay, it's a little problem, he's collapsed, right, he's not that degenerate, so this is more traumatic, he was actually in quite a situation. a traumatic accident with IC. I'll give you that hint, but from this mid-sagittal view, can we say anything else? Is there a hernia here? No, I don't see any balls protruding from the back. Is there a Spondo thesis? I haven't covered that. but go to my The spond thesis page, that's where the upper bone slides forward due to a break in the posterior arch. Well, maybe a little, but everything looks pretty good there now.

This is a good example. You can't, you couldn't. send me this picture and say Doc, am I okay? I don't know, I have to look at all the images, so if we scroll down to the parasagittal view, look what we have here, we have a grade one Lis spondo thesis, look at how this. here are the L5 vertebrae, look how it slid this way, it slid forward because here is the back of the S1 segment here and here is the back of the L5 segment, those should be even, like all of these line up here , look, they line up very well, so this is a first degree Loess thesis and we're starting to see a little bump here, so it could be an insight, well, it could be that we're not completely sure, let's make one more cut Oh my gosh, look at this we have here. the L5 here is the S1, can you see it well?

There is a massive insight here that is very lateral. It's stuck right in the neural framework. Look, these frames are all open here. No problem. This is the only part. This little fat top corner is the only one. thing that is open, so we have a massive dysextrusion that happened to this basketball player and knocked him out of the season. Well, we have reached the end of this video. I hope you learned something about how to read your MRI again. Completely complete, go to my car.com website and go to the tab titled MRI and you will find a wealth of information that goes into much more depth than what I presented here.

If you're still confused about your own MRI, why not? Hire me to talk to you for an hour on the phone about it. I offer a coaching service for that purpose or if you are scheduled for surgery and are unsure whether to try a micro discectomy or an endoscopic discectomy or a laser. discectomy or a Perth procedure said procedure nucleoplasty or bacoplasty call me. I can help you figure things out. There is a lot of information about this on my website under the training sessions tab, so feel free to check that out too. Look at what my coaching clients have been saying.

I've spoken to patients all over the world from all walks of life, from physicists to Surfer Dudes from Australia, so I'm comfortable speaking at any level and again thanks for watching this video and we'll talk to you next time