Lea Alhilali, MD Profile picture
Jul 22, 2022 10 tweets 6 min read Read on X
1/Remembering spinal fracture classifications is back breaking work!

A #tweetorial to review the scoring system for thoracic & lumbar fractures—“TLICS” to the cool kids! #medstudenttwitter #medtwitter #radres #FOAMed #FOAMrad #neurorad #Meded #backpain #spine #Neurosurgery
2/We’ll talk about the imaging part of TLICS. TLICS scores a fx on (1) morphology & (2) posterior ligamentous complex (PLC) injury. Let’s start w/morphology. W/only mild axial loading, you get the simplest fx, a compression fx—like a simple long bone fx--worth 1 pt.
3/As the axial force grows, this becomes a burst fx with retropulsion of the posterior vertebral body—just as greater force causes more comminution in long bone fxs. A burst is worth 2 points.
4/If the force is shearing, rather simply compress a vertebral body, you rip the connection between the vertebral bodies—this is the equivalent of pulling on a long bone & causing its dislocation from its joint or connection with another bone. This is worth 3 points
5/Similar to shear forces, distracting forces will rip the vertebral bodies apart. But rather than sliding forward or back, the vertebral bodies are pulled up or down, resulting in a vertical gap between the vertebral bodies. This is worth 4 points
6/This summarizes the TLICS scoring for fracture morphology. The higher the number, the greater the force and injury to the spine—ranging from simple compression fxs worth only 1 point to where the spine is literally ripped apart—a distraction injury, worth 4 points.
7/The next TLICS imaging finding is the integrity of the PLC. If it is intact, you get 0 pts. If you needed a tweetorial for that, well…I can’t help you much. If there is edema, but no true rupture on MRI, that is worth 2 pts. True disruption on MRI is worth 3 pts.
8/Here is an example of suspected injury—edema is seen in the posterior ligamentous complex, but the T2 dark lines that are the ligaments themselves appear intact. This is worth 2 pts.
9/If you can find a true disruption or gap in the T2 dark line of the ligament, that is considered truly disrupted and worth 3 points.
10/Here is the summary of the scoring for PLC injury in TLICS. Edema is suspicious, but only a true gap is considered injured.

So now you know how to score imaging findings in thoracolumbar fxs--I hope that takes a load off your back!

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More from @teachplaygrub

Jul 25
1/Time to go with the flow!

Hoping no one notices you don’t know the anatomy of internal carotid (ICA)?

Do you say “carotid siphon” & hope no one asks for more detail?

Here’s a thread to help you siphon off some information about ICA anatomy! Image
2/ICA is like a staircase—winding up through important anatomic regions like a staircase winding up to each floor Lobby is the neck.

First floor is skullbase/carotid canal. Next it stops at the cavernous sinus, before finally reaching the rooftop balcony of the intradural space.Image
3/ICA is divided into numbered segments based on landmarks that denote transitions on its way up the floors.

C1 is in the lobby or neck.

You can remember this b/c the number 1 looks elongated & straight like a neck. Image
Read 10 tweets
Jul 23
1/My hardest thread yet! Are you up for the challenge?

How stroke perfusion imaging works!

Ever wonder why it’s Tmax & not Tmin?

Do you not question & let RAPID read the perfusion for you? Not anymore! Image
2/Perfusion imaging is based on one principle: When you inject CT or MR intravenous contrast, the contrast flows w/blood & so contrast can be a surrogate marker for blood.

This is key, b/c we can track contrast—it changes CT density or MR signal so we can see where it goes. Image
3/So if we can track how contrast gets to the tissue (by changes in CT density or MR signal), then we can approximate how BLOOD is getting to the tissue.

And how much blood is getting to the tissue is what perfusion imaging is all about. Image
Read 18 tweets
Jul 21
1/Do you know all the aspects of, well, ASPECTS?

Many know the anterior circulation stroke scoring system—but posterior circulation (pc) ASPECTS is often left behind

25% of infarcts are posterior circulation

Do you know pc-ASPECTS?!

Here’s how to remember pc-ASPECTS! Image
2/Many know anterior circulation ASPECTS.

It uses a 10-point scoring system to semi-quantitation the amount of the MCA territory infarcted on non-contrast head CT

If you need a review: here’s my thread on ASPECTS: Image
3/But it’s only useful for the anterior circulation.

Posterior circulation accounts for ~25% of infarcts.

Even w/recanalization, many of these pts do poorly bc of the extent of already infarcted tissue.

So there’s a need to quantitate the amount of infarcted tissue in these ptsImage
Read 12 tweets
Jul 2
1/The medulla is anything but DULL!

Does seeing an infarct in the medulla cause your heart to skip a beat?

Does medullary anatomy send you into respiratory arrest?

Never fear, here is a thread on the major medullary syndromes! Image
2/The medulla is like a toll road.

Everything going down into the cord must pass through the medulla & everything from the cord going back up to the brain must too.

That’s a lot of tracts for a very small territory. Luckily you don’t need to know every tract Image
3/Medulla has 4 main vascular territories, spread out like a fan: anteromedial, anterolateral, lateral, and posterior.

You don’t need to remember their names, just the territory they cover—and I’ll show you how Image
Read 18 tweets
Jun 30
1/Time is brain! But what time is it?

If you don’t know the time of stroke onset, are you able to deduce it from imaging?

Here’s a thread to help you date a stroke on MRI! Image
2/Strokes evolve, or grow old, the same way people evolve or grow old.

The appearance of stroke on imaging mirrors the life stages of a person—you just have to change days for a stroke into years for a person

So 15 day old stroke has features of a 15 year old person, etc. Image
3/Initially (less than 4-6 hrs), the only finding is restriction (brightness) on diffusion imaging (DWI).

You can remember this bc in the first few months, a baby does nothing but be swaddled or restricted. So early/newly born stroke is like a baby, only restricted Image
Read 10 tweets
Jun 27
1/”I LOVE spinal cord syndromes!” is a phrase that has NEVER, EVER been said by anyone.

Do you become paralyzed when you see cord signal abnormality?

Never fear—here is a thread on all the incomplete spinal cord syndromes to get you moving again! Image
2/Spinal cord anatomy can be complex. On imaging, we can see the ant & post nerve roots. We can also see the gray & white matter. Hidden w/in the white matter, however, are numerous efferent & afferent tracts—enough to make your head spin. Image
3/Lucky for you, for the incomplete cord syndromes, all you need to know is gray matter & 3 main tracts. Anterolaterally, spinothalamic tract (pain & temp). Posteriorly, dorsal columns (vibration, proprioception, & light touch), & next to it, corticospinal tracts—providing motor Image
Read 20 tweets

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