Neutral Lateral Cervical Flashcards
Soft tissue front of spine
Retropharyngeal - C4 - 7mm
Retrolaryngeal space - 14mm
Retrotracheal space - C6 - 21/22mm
If soft tissue is larger than vertebral body
Soft tissue swelling due to trauma, infection, malignancy
ADI space
Normal ADI 1-3mm adult
If ADI is the size of the anterior tubercle
Increased ADI - transverse ligament laxity
Brace the neck and refer out
Compare spinolaminar of C1 to C2
Atlas moved anterior or posterior
Atlas moved anterior
Increased ADI
Fractured dens
Non-union of the dens
Agenesis of the dens
Atlas moved posterior
Fractured dens
Non-union of the dens/unstable odontoidium
Agenesis of the dens
Check the front of the bodies
Syndesmophytes
Hyperostosis
Lipping/spurring
Marginal syndesmophytes
AS
Pushed up against front of the vertebral bodies and disc space
BILATERAL
Non-marginal syndesmophytes
Reactive arthritis - +STD panel, vinereal disease, arthritis, iritis, conjunctivitis, urethritis
PA - silver scales, pitted nails, cocktail sausage digits
AS aka
Marie strumpell’s disease
AS about
Most commonly males 15-35
LBP with morning stiffness
Iritis/uveitis
AS orthos
Chest expansion
Forrestier’s bowstring
Lewin’s supine
Radiographic signs AS
Bilateral SI joint fusion - ghost joints/star sign
Erosion of vertebral corner - Romanus lesion
Spine - shiny corner sign, bilateral marginal syndesmophytes, thin eggshell calcif around disc, squaring of vertebral bodies, bamboo spine, dagger sign, trolley track sign, poker spine, andersson lesion
AS labs
+HLA-B27
-Rheumatoid
+ESR
Case management AS
Co-treat with Rheumatologist
Can adjust but avoid areas that are actively inflamed or involved
Non-marginal syndesmophytes description
Flows out into the soft tissue (unilateral or bilateral)
Reiter’s disease
PA
Reiter’s disease aka
Reactive arthritis
Vinereal disease
Reiter’s description
20-30 Conjunctivitis Urethritis Iritis Arthritis Ulcers on feet Apthous stomatitis Calcaneal spur (lover’s heel)
Reiter’s caused by
Chlamydia
Reiter’s labs
HLAB27
+STD panel
REiter’s is like DISH but
Facets are fused
Case management reiter’s
Refer to PCP or Rheumatologist
PA description
20-50 Silver scaly lesions on extensors Pitted nails Cocktail sausage digits Auspitz sign
Lab PA
HLA B27
-Rheumatoid
Case management PA
Refer to Rheumatologist
DISH aka
Anterior spinal bridging
Exostosis of 4 or more segments
Hyperostosis
Candle wax drippings
DISH
DISH description
Males >40
Neck stiffness
Pain on swallowing
Radiographic findings DISH
Flowing hyperostosis Candle wax drippings 4 continuous segments involved Disc space preserved Facets preserved
Long-term DISH
Postural deformity and loss of proper motion - early onset DJD
DISH associated with
Diabetes mellitus - eye exam and labs for diabetes
DISH can cause ossification of the
PLL
Case management DISH
Endocrinologist referral
Orthopedist referral
You can adjust but no audibles
Lipping and spurring
DJD
Infection
DJD
Ant vertebral body comes out to meet like pursing lips
Lipping and spurring (osteophytes)
Decreased disc space
Subchondral sclerosis of endplates
Usually stiffens with rest and improves with activity
DJD
DJD complications
Spinal stenosis
IVF encroachment
Only condition that alters the disc space in size and/or color and affects the surrounding endplates
Infection
Pt presents with a fever, chills, possible hx of trauma/surgery, and a warm, tender, swollen joint
Infection
Infection case management
Refer out
Chest x-ray
Sputum culture
WBC count
Avulsion fractures aka
Teardrop fracture
Avulsion fracture
Avulasion of the anterior inferior aspect of the vertebral body from a hyperextension trauma/whiplash
Avulsion fracture associated with
Acute anterior cervical cord syndrome
Loss of motor, pain, and temperature
Avulsion fractures are most common in
Cerivcal spine
Most commonly seen at C2
Case management avulsion fracutre
Flex/ext
Immediate referral for orthopedic surgical consult
Compression fracture
Loss of 25% or more body height
MOP IT
MOP IT
Malignancy Osteoporosis Pagets Infection Trauma
Malignancy
Destroys both ant and post body height
Osteoporosis
Only ant body height destroyed - esp thoracic
Infection
Fever
WBC
Trauma
Hx trauma
Check the base of the dens for a radiolucent line
Fractured Dens
Non-union of the dens (os odontoidium)
Agenesis of the dens
Mach line
Fractured dens
Bone displaced from itself Jagged edges Acute Hx trauma Pain THIN DISPLACEMENT
Non-union of the dens (os odontoidium)
Smooth edges Cortical margins around united pieces Chrnoic No displacement No hx trauma - usually asymptomatic Anterior tubercle gets white Smooth edges THICK lines REFER orthopedist
Agenesis of the dens
Missing ADI
Color of where dens should be is similar to the color of the C2 body
Mach line
Rule out other three - fractured dens, non-union of the dens, agenesis of the dens
Approximate the dens for
Height
Alignment
Color
Height dens
Majority of dens should be below base of occiput - if not = basilar invagination - paget’s fibrous dysplasia, tauma
Similar to height of C2 body
Mensuration lines height dens
McGregor’s
Chamberlains
McGregors
Back of hard palate to base of occiput
8mm male
10mm female
Chamberlains
Back hard palate to posterior foramen magnum
No more than 7mm above line
Alignment dens
Should be in line with C2 body - no = fx Jagged and displaced Brace the neck Refer to orthopedic surgeon Leaning dens = sign of fx or os but usually fx
Color dens
Color of where dens is should be whiter than the body
If dens is missing color is similar to C2 body
Check the bodies for alterations of color and shape
Color - darker/lighter
Shape - PFC
Color darker
Lytic mets
Multiple myeloma
Multiple myeloma aka
Plasma cell sarcoma
Multiple myeloma description
Aplastic anemia Thrombocytopenia >50 Weight loss Anemia Chachexia Plasma cell leukemia Bone pain worse at night Nothing palliative/provocative
Most common primary malignancy in adults
Multiple myeloma
Multiple dark densities that are similar in size (punched out lesions) in extremities
Can cause pathological collapse (vertebra plana)
Mm
Rain drop skull
Multiple myeloma
Labs mm
Reversal of AG ratio IgM spike on immune-electrophoresis Bence jones proteinuria ESR Aplastic anemia aka normochormic normocytic anemia
Special test mm
COLD on bone scan
Refer to oncologist
Pathological compressions
Vertebrae plana
Dec in post body height but will spare the pedicles (lytic mets will not)
Lytic mets
Signs of malignancy >40 Recent unexplained weight loss Skeletal pain worse at night Cachexia Nothing palliative/provocative
Lytic mets description
Moth eaten or permeative pattern of destruction - all holes different sizes
Eats away bone
Eats pedicles
Vertebra plana, winking owl, swiss cheese appearance
Lab lytic mets
Alkaline phosphatase
Special test lytic mets
HOT on bone scan - destruction will be hottest part
Whiter color bodies
Hodgkin’s
Blastic mets
Paget’s
Hodgkins
Cervical only
Cortical thickening/enlargement/deformity
Most common form of mets in ages 20-30
Ivory white vertebrae with anterior body scalloping
Unilateral hilar lymphadenopathy in white males seen on PA chest view
Hodgkin’s
Confirm hodgkin’s by
Biopsy
Reed sternberg cells
Blastic mets
Obviously whiter but not bigger
>40
Ivory white vertebrae no cortical thickening or enlargement
Labs blastic mets
Increased alkaline phosphatase
Special test blastic mets
Bone scan
Paget’s aka
Osteitis deformans
Paget’s
Male >50
Causes cortical thickening Picture frame vertebrae Increased bone density Coarsened trabeculae Bone enlargement Basilar invagination
Paget’s
Labs paget’s
Increased alkaline phosphatase
Urinary hydroxyproline
Special test paget’s
Bone scan
Alteration of shape
PFC
PFC
Paget’s
Fractures
Congenital
Paget’s
Cortical thickening
Enlargement
Deformity
Fractures
Loss of anterior body height 25% or more
Vertebral plana - pathological collapse = loss of both anterior and posterior body height
Most common cause fx
Mm
Mets
Congenital anomalies
Congenital block
Klippel-feil syndrome
Congenital block
Two segments fused together from birth
Wasp waise appearance
Hypoplastic disc/rudimentary disc/remnant disc
Fusion posterior aspects
Klippel-feil syndrome
Multiple congenital blocks
Sprengle’s deformity
Omovertebral bone - calcification of the rhomboids
DJD aka
DDD
Spondylosis
Arthritis
Lipping and spurring (osteophytes)
Decreased disc space
Subchondral sclerosis of endplates
Vacuum phenomenon
DJD
Vacuum phenomenon aka
Knuson’s phenomenon
IVOC
Phantom disc
Infection aka
Infective arthritis Infective spondylitis Septic arthritis Osteomyelitis Pott’s disease
Check the posterior arch of atlas
Missing
Vertical radiolucency
Missing posterior arch atlas
Surgery
Malignancy
Agenesis
Missing post arch C1 - surgery
Must see signs of surgery on film like staples, wires
Missing post arch C1 - malignancy
M/c lytic mets teeth marks/jagged
Missing post arch C1 - agenesis
Smooth borders
Clean margins
Enlargement
Whiter ant tubercle
Vertical radiolucency post arch atlas
Fracture
Non-union
Check teh pedicles of C2 for fractures
Hangman’s fracture - bipedicular fracture - posterior type 4 spondylolisthesis
Hyperextension trauma - whiplash
Posterior bodies - height and destruction
Decreased ant and post = pathological fx
Teeth marks in bone = lytic mets
MOP IT
Pathological fx
Vertebral plana
Pancake vertebrae
Wafer thin vertebrae
Coin on end vertebrae
Pedicles
Check for slipping bodies - subluxation or dislocation
Slippage of VB ant or post by 10-15% with facets still lining up
Break in George’s line
Subluxation pedicles - slipping bodies
Slippage of the vertebral body ant or post by 25% or more with face perching and spinous fanning
Brace the neck
Refer to orthopedic surgeon/ER
Pedicle - dislocation
Facets
Dislocation
Destruction
Fusion
Dislocation facets
Trauma or ligament instability
Destruction facets
Facet arthrosis whiter in facet area - teeth marks - rat bite erosinos in RA
Fusion facets
Congenital or acquired
Congenital fusion facets
Two facets fused as one - megaspinous with one spinolaminar line
Acquried fusion facets
Facets fused with separate distinct spinal laminar lines
RA or AS
Two conditions cause acquired fusion of the facets
AS - marginal syndesmophytes and thin eggshell calcification
RA - only affects synovial joints
Check spinolaminar lines and spinouses
Congenital surgical malignancy
Fractures
Bone displaced from itself
C6,C7, T1
Clay shoveler’s fractures
Hyper-flexion trauma
Double spinous sign seen on AP view
Spinous fx
Missing spinolaminar line is a
Spina bifida on the lateral view
B9 deficiency
C1 = spondyloschisis
