Spine, the newest back stabber

Something aggravating is often referred to as a “pain in the neck.” Well, in my work, perhaps the expression should be “pain in the spine.” In previous posts, I talked a lot about German-specific issues. Today, I want to show you a challenge I sometimes encounter, regardless of whether the language is English, German, etc.: the many different ways to describe which spine segment the pathology refers to.

Let me start with a short introduction of the spine in radiology reports. Our spine consists of many vertebrae, and between almost all of them there are disks that act as cushions, enabling us to move around without pain. The spine can be grouped into four segments: cervical, thoracic, lumbar and sacral spine – from head to buttock. To make it easier to point to a certain vertebra, each segment has an abbreviation: C, Th, L and S – and yes, we do have additional abbreviations in German. Now each vertebra can be identified by the spine segment abbreviation and the number (again from top to bottom); for example, the first lumbar vertebrae is called L1. To identify which disk we are talking about, we just mention the neighboring vertebrae: Th12/L1 is the disk between Th12 and L1.

Now, this doesn’t sound much like a challenge at all. True, if a single disk or vertebra is mentioned, it isn’t. But we are talking about natural language and human beings. We tend to try to shorten everything, even if in the end it does make everything harder. In the same way that poor communication can create problems between friends, a radiologist’s abbreviated notation can result in problem for the person who – or in our case the machine that – has to interpret it. How would you describe multiple vertebrae together, if they are following each other in order? Again, I was surprised by the number of different possible ways to do it. Let me show you three confusing examples:

  • L1/2 This is the most common way, and I love it – until a pathology is mentioned which does not affect the disk, but rather the vertebra. In that case, it is not always clear to which vertebra the description refers.
  • L3 – 1 Without context, you will be lost. Are they talking top to bottom, which would make the last vertebra S1? Or is it bottom to top, meaning the “1” is L1? With context clues (e.g. L1 was previously mentioned), the mystery vertebra can often be determined.
  • L5/1 Similar to the prior example, but in this case, I really hope we are allowed to assume it is the shortened version of L5/S1.

Even if not perfect, these examples of pathology descriptions are mostly structured and easy enough to figure out. Can you hear the “but” which will follow? I work with natural language, which continually presents new challenges. As I’ve written about in previous blog posts, adding in the German language aspect tends to complicate things even further:

  • L1 compared to L2 Often used if L1 is shifted and does not align with L2; usually some measurements are added to describe the degree of the shift.
    In German, the word for “compared to” is “gegenüber” but in Switzerland it is often shortened to “über” (more like “above” in English). The word “gegenüber” implies the comparison and the pathology applies only for the left side. The word “über” tells us only that the left side is above the right side. If it was written by a Swiss person in this context, we may assume they mean the same as “gegenüber” – but I do not know if they are.
    To make it worse, when multiple pathologies are mentioned in the same sentence, I start to struggle. For example, “L1 compared to L2 is shifted and has a fracture.” Now, does the pathology “fracture” apply for both vertebrae or only L1?
  • L1 till L5 Now this is a funny example that still gives me a headache! Let me start with the translation, in German it is written as “L1 bis L5”. The word “bis” can be used in many different contexts, and based on the context, the right part is included or not. The best examples can be made using date and time: If some business has opening hours “13 bis 16 Uhr” (1pm till 4pm), after 4pm sharp, they will be closed. If the open weekdays are mentioned with “Montag bis Freitag” (Monday through Friday), you still can go there on Friday. Now an example where it is not clear: “Senden sie mir die Unterlagen bis Mittwoch” (Send me the documents until Wednesday). In this example, it is unclear if sending the documents by Wednesday evening is sufficient, or if they are needed by Wednesday morning for the other person to process.
    And this applies to the vertebra too: Is L5 included or not in this example?
    With specificity in the usage of language, it is possible to conclusively state whether a particular part (L5 in our example) is included. Depending where you live, it is either “bis einschliesslich” (to and including) for the Germans and “bis und mit” (to and with) for the Swiss.
    Because both cases, with specification and without, it is now not clear if there are radiologists who are extremely precise, or that “bis” without anything else excludes the right part.

Even if the topic has a clear naming convention (e.g. L1), it is still possible to make it hard to understand which parts of the spine are addressed when a range of multiple vertebrae is described in the report. Once again, I’m amazed (and occasionally exasperated) by what can be done with natural language! Sometimes it really is a pain in the neck – or the spine.

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