Cervical Anomalies/Variants Flashcards
(96 cards)
1
Q
What is the most commonly seen x-ray “abnormality”?
A
Anomalies and variants
2
Q
What are the three rules of anomalies?
A
- Most commonly seen in transitional spinal areas
- When you see one, look for others
- The other abnormality is usually soft tissue
3
Q
If an abnormality is a congenital anomaly, how are its margins likely presenting?
A
Smooth, well-rounded, corticated margins
4
Q
If a lesion, such as a missing pedicle, displays hypertrophy contralaterally, is it more likely an anomaly or metastasis?
A
Anomaly
hypertrophy compensates for load demands over time
5
Q
Is this missing pedicle more likely congenital or due to metastatic disease?
What about the radiograph lets you know?
A
Congenital
Sclerosis and hypertrophy of pedicle contralateral to absent pedicle
6
Q
Is this missing pedicle more likely congenital or due to metastatic disease?
What about the radiograph lets you know?
A
Osteolytic metastasis
No evidence of sclerosis or enlargement of contralateral pedicle
also destruction of lamina, spinous process, and part of lateral body
7
Q
What is Mach effect?
A
Unfortunate confluence of shadows
can trick you into thinking fracture
8
Q
Instability is generally assessed using what imaging?
A
Flexion/extension radiographs
9
Q
What numerical value qualifies as translational instability in the cervical spine?
A
3.5mm
10
Q
What numerical value qualifies as translational instability in the lumbar spine?
A
4 or 4.5mm
depends on source
11
Q
What numerical value qualifies as angular instability in the cervical spine?
A
11 degrees
12
Q
What differing numerical values qualify as angular instability?
L1-L3:
L4/L5:
L5/S1:
A
L1-L3: 15 degrees
L4/L5: 20 degrees
L5/S1: 25 degrees
13
Q
If there is upper cervical instability, which structures may be involved/deficient?
A
Transverse ligament and/or dens
14
Q
Upper cervical instability refers to excess ___ plane motion at C1/C2.
A
sagittal
15
Q
What are the normal ADI ranges for adults and children?
A
Adults: <3mm
Children: <5mm
16 is the cutoff between child and adult
16
Q
If the transverse ligament is lax, torn, or destroyed, the ADI will be ___.
A
increased
17
Q
What is the DDx if the dens/odontoid is causing upper cervical instability?
A
- Os odontoideum
- Type 2 odontoid fracture
- Odontoid agenesis (rare)
18
Q
upper cervical instability
If C1 translates forward and the ADI is increased, what is the differential diagnosis?
A
Transverse ligament problem
26+ possibilities
19
Q
upper cervical instability
If C1 translates forward and the ADI is decreased or absent, what is the differential diagnosis?
A
Dens problem:
- os odontoideum
- type 2 odontoid fracture
- odontoid agenesis
20
Q
upper cervical instability
If C1 translates backward, what is the differential diagnosis?
A
Dens problem:
- os odontoideum
- type 2 odontoid fracture
- odontoid agenesis
21
Q
What are two spinal anomalies that can occur in all areas of the spine?
A
- Spina bifida occulta
- Congenital fusion
22
Q
What are the two main types of spina bifida?
A
- Spina bifida vera
- Spina bifida occulta
23
Q
What is spina bifida vera?
A
- Wide bony defect of the posterior elements
- Herniation of the meninges and contents outside of the spinal canal (sac)
meningocele or myelomeningocele
diagnosed in utero
24
Q
What is spina bifida occulta?
A
Failure to unite the 2 halves of the posterior vertebral arch
25
What is the clinical significance of a solitary spina bifida occulta?
Questionable
| "don't mean shit" diagnosis
26
Solitary spina bifida occulta is seen in higher incidence of patients with ___.
spondylolysis
27
If there are multiple spina bifida occulta, what is a possibility to consider?
Underlying neurologic problems
| spinal cord anomaly possible
28
Given this thoracocervical radiograph, what is your biggest concern?
Underlying neurologic problems
| multiple SBO
29
Looking at a lateral view radiograph first, the ___ line will be absent if there is spina bifida occulta.
**spinolaminar junction** line
30
After looking at a lateral view, an AP radiograph will display a ___ if there is spina bifida occulta.
vertical cleft in the posterior elements
31
What are the most common levels for spina bifida occulta to occur?
Transitional regions:
* S1
* C1
* L5
* T12
* L1
32
Where is the SBO?
What evidence is present?
SBO at S1
Vertical cleft seen at spinous
33
What is spondyloschisis?
SBO at C1
| just call it SBO
34
On a lateral radiograph, C1 has an absent spinolaminar junction line.
What other feature may be present if there is spina bifida occulta at C1?
Anterior arch hypertrophy
35
What condition is most likely present in this radiograph?
Spina bifida occulta at C1
## Footnote
note: anterior arch hypertrophy, absent spinolaminar junction line
36
During gestation, vertebral bodies arise from the ___.
Occasionally, there will be a failure of ___, leading to **congenital fusion**.
vertebral bodies arise from the **notochord**
there will be failure of **somite segmentation**
leading to **congenital fusion**
37
Congenital fusion most commonly affects two segments.
What are the most common levels for this to occur?
* C5/C6
* C2/C3
* T12/L1
38
Are these block vertebrae more likely congenitally or surgically fused?
What makes you think so?
Congenital fusion
* Hypoplastic disc
* "Wasp waist" deformity
* Fusion of the facets is more frequently congenital (50%)
39
What is a pathology to consider if there are greater than two segments involved in congenital fusion?
Klippel Feil syndrome
40
What are the radiographic findings associated with congenital fusion?
* Hypoplastic disc
* "Wasp waist" deformity
* Frequent (50%) fusion of the facets
41
What is an immediate concern for adjusting a patient with congenital fusion of C2/C3?
Biomechanical instability
| flexion/extension radiographs before treatment
42
What sort of referral would you make for a chronically unstable spine?
What would you do for an acutely unstable spine?
Chronically unstable = **neurosurgical consultation**
Acutely unstable = **emergency transport**; collar patient and lay then down
43
What are some concerns if a patient has surgical spinal fusion?
* Instability
* Did the fusion take?
| flexion/extension radiographs
44
What is the diagnostic criteria for Klippel Feil syndrome?
Multiple congenital block vertebrae in the cervical spine
45
If a patient has multiple congenital block vertebrae in the cervical spine, what is this diagnostic of?
Klippel Feil syndrome
46
30% of those with Klippel Feil syndrome have a webbed neck.
Which bony changes would lead to this presentation?
* Omovertebral bone
* Sprengel deformity
47
Besides multiple congenital block vertebrae in the cervical spine, what are other frequent bony abnormalities found with Klippel Feil syndrome?
* **Omovertebral bone**: bone formed between spine and scapula
* **Sprengel deformity**: non-descended scapula
48
What are some biomechanical concerns for someone with Klippel Feil syndrome?
Hypermobility/instability
| flexion/extension radiographs
## Footnote
multiple congenital fusions in cervical spine
49
Klippel Feil syndrome is associated with ___ and ___ anomalies. Thus, a chiropractor should make ___ and ___ referrals.
| viscera
**cardiac** and **renal** anomalies
**cardiology** and **urology** referrals
## Footnote
spine, heart, and genitourinary system develop around the same time
50
51
What is the term for congenital fusion of C0/C1?
Occipitalization
52
Occipitalization is relatively common.
The most common symptom is ___, which can be confused for a diagnosis of ___ without radiographs.
most common symptom is **headaches**
confused for a diagnosis of **spasm** without radiographs
53
Occipitalization is frequently associated with what other bony anomaly?
C2/C3 fusion
54
What is our primary concern for someone with occipitalization?
Atlantoaxial instability: stresses **transverse ligament**
| upper cervical instability is technically acquired due to fusion
55
Cervical radiographs are mostly normal, however, C1 appears to be missing.
What is the most likely possibility?
Occipitalization
| skull base morphology
56
The average diameter of the dens is ___.
The ADI should be ___ in comparison.
8mm
less than half of diameter
57
When assessing for occipitalization, ___ line is abnormal because ___.
**McGregor's** line (posterior hard palate to most caudal point on occipital bone) is abnormal because **dens is within foramen magnum**
58
A lateral cervical radiograph demonstrates that the dens is within the foramen magnum.
What anomaly is present and what is the appropriate referral?
Occipitalization
Neurosurgical consult
59
What is a chiari malformation?
Herniation of the cerebellum (tonsils) more than **5mm** beyond the margin of the foramen magnum
| appears peg-shaped/pointy
60
Chiari malformation can cause ___ due to ___. Thus, a brain MRI is needed to assess damage.
**hydrocephalus** due to **Magendie and Luschka foramina being blocked**
61
Chiari malformations are associated with ___ formation and ___.
**syrinx** formation and **syringomyelia**
62
What is the term for fluid in the central aqueduct?
Syrinx/Syringomyelia
## Footnote
associated with Chiari malformation
63
Patient has pain and loss of heat/cold sensation is a cloak pattern across their neck and shoulders.
Which pathology is this characteristic of?
Syrinx/Syringomyelia
## Footnote
associated with Chiari malformation
64
Syrinx/syringomyelia most commonly affects the ___ extremity.
upper
| cloak-like distribution of symptoms
## Footnote
associated with Chiari malformation
65
What sort of symptoms are caused by syrinx/syringomyelia
* Pain
* Loss of pain sensation (may lead to neuropathic arthropathy)
* Loss of temperature sensation
| fluid in the central aqueduct
## Footnote
cloak-like distribution
66
Small syrinx/syringomyelia may not be a problem, but as it enlarges, it can ___.
press on the spinal cord
## Footnote
causes pain, loss of pain sensation, loss of temperature sensation
67
What presentations would help differentiating between posterior arch agenesis and osteolysis of the posterior arch?
If posterior arch agenesis:
* stress hypertrophy at anterior tubercle
* C2 megaspinous
68
Why are flexion/extension radiographs important when there is posterior arch agenesis?
Transverse ligament insufficiency
## Footnote
may be missing or not attached
69
What is the term for ossification of the atlantooccipital membrane?
Posterior ponticulum
70
Radiographs display partial ossification from lateral masses to the spinous process of C1.
Which ligament is ossified?
Which pathology is present?
Arcuate ligament
Posterior ponticulum
## Footnote
atlantooccipital membrane can be partially or completely ossified
71
Patient complains of migraines and a cervical radiograph is taken. It is revealed they have posterior ponticulum.
Is chiropractic contraindicated?
No, they can be treated
| questioned clinical significance/incidental finding
72
Why do the Special Olympics require x-ray clearance for certain sports if someone with Down Syndrome is to participate?
Transverse ligament anomaly causes atlantoaxial instability
73
Down Syndrome has large numbers of associated anomalies.
30% are born without ___.
transverse ligament
| atlantoaxial instability
74
A patient with Down Syndrome has a lateral cervical radiograph that reveals an increased ADI in neutral.
What does this tell you?
* Confirmed instability
* No flexion/extension radiographs needed
* Contraindication to manipulation
75
What is os odontoideum?
Odontoid separated from the C2 vertebral body
## Footnote
smooth, well-rounded, corticated margins
76
Patient has os odontoideum with chronic upper cervical instability.
Which referral is necessary for this patient?
Neurosurgical consult
| unstable by definition
77
Is os odontoideum congenital or acquired?
More likey a pediatric/toddler fracture that healed non-union
78
Os odontoideum presents a concern for ___ effect.
How does this occur?
**guillotine** effect
C1 goes forward, posterior elements hit the spinal cord
79
What is the most common presentation of a patient with os odontoideum?
Clinically silent, even with gross instability
80
What is Steele's rule of thirds?
Within C1's vertebral foramen, 1/3 should be occupied by the dens (8mm), 1/3 by the spinal cord, and 1/3 by space
81
How common is agenesis of the odontoid?
Super rare
82
What are the results of agenesis of the odontoid?
Instability accelerates degeneration, destroying C1/C2
83
What is os terminale of Bergmann?
Ununited secondary ossification center at the tip of the odontoid
| smooth, round, corticated margins
84
A patient's odontoid is separated from their C2 vertebral body, appearing to have smooth, well-rounded, corticated margins. Their cervical spine is unstable.
What pathology is this characteristic of?
Os odontoideum
85
A patient's secondary ossification center at the tip of their odontoid is separated from their C2 vertebral body, appearing to have smooth, well-round, corticated margins. Their cervical spine is stable.
What pathology is this characteristic of?
Os terminale of Bergmann
86
What is the clinical significance of os terminale of Bergmann?
Stable, incidental finding
87
Cervical ribs most commonly arise from ___.
C7
| partial or complete
88
What is another anomaly that may be mistaken for a cervical rib?
Elongation of cervical transverse process
89
Which orthopedic test is meant to determine the presence of a cervical rib?
Adson's test
90
Cervical ribs are usually asymptomatic, but can have ___.
neurovascular compromise
| e.g. TOS
91
Cervical ribs are common, but TOS is uncommon.
What is the average onset of TOS if there is a cervical rib present?
Mid 30s
92
Patient presents with symptoms of TOS and is discovered to have a cervical rib.
Is this a contraindication to manipulation?
No, treat a patient with cervical ribs
| their scalenes are probably also annoyed
93
What is Eagle Syndrome?
Mechnical dysphagia with stylohyoid ligament ossification
94
If stylohyoid ligament ossification is suspected, what questions should be asked to assess if Eagle Syndrome is present?
How is it swallowing solids?
## Footnote
Eagle Syndrome = styloyoid ligament ossification + mechanical dysphagia
95
What are some ways stylohyoid ligament ossification presents?
* Mostly asymptomatic
* Eagle Syndrome (dysphagia)
* Vertebral artery insufficiency
* Fracture (of the ligament)
96
