The cervical spine in rheumatoid arthritis: relationship between neurologic signs and morphology on MR imaging and radiographs

 Objective. Comparison of clinically observed neurologic long tract signs in a heterogeneous group of patients with rheumatoid arthritis (RA), with morphologic abnormalities of the cervical spine as depicted on radiographs and magnetic resonance (MR) images. Design. The patients were prospectively assigned to one of three classes on the basis of their neurologic status. Lateral cervical spine radiographs and sagittal T1-weighted and gradient echo images were performed. The qualitative MR features evaluated were erosion of the dens and atlas, brain stem compression, subarachnoid space encroachment, pannus around the dens, appearance of the fat body caudal to the clivus, and the signal intensity of the pannus. The quantitative imaging parameters were the cervicomedullary angle and the distance of the dens to the line of McRae. Patients. Sixty-three consecutive patients with RA and subjective symptoms, especially neck or occipital pain, and/or clinical objective signs consistent with a compromised cervical cord were included in this study. Results and conclusions. Damage documented with radiographs and MR imaging in patients with RA is often severe, even in those without neurologic signs (class 1). None of the abnormalities confined to the atlantoaxial level correlated significantly with neurologic classification. Subarachnoid space encroachment anywhere in the entire cervical spine did correlate significantly with neurologic classification.     

Digital enlargement in tuberous sclerosis

A 23-year-old woman with a medical history significant for tuberous sclerosis presented with symptoms of postpartum endometritis. Focal gigantism of the third digit of her right hand was incidentally noted and is reported to be a rare manifestation of tuberous sclerosis. Received: 19 October 1998 Revision requested: 3 November 1998 Revision received: 16 November 1998 Accepted: 17 November 1998     

Degenerative change in the cervical spine and load-carrying on the head

 Objective. To evaluate the relationship between load-carrying on the head and the development of degenerative change in the cervical spine. Design and subjects. A case-control study was performed with 35 individuals who had carried loads on their head (carriers) and 35 persons who never had carrier loads on their head (non-carriers). A scoring system was utilized for the assessment of the degenerative change in the cervical spine at the C3/C4, C4/C5, C5/C6 and C6/C7 levels on lateral cervical spine radiography. A total score was calculated by summing the scores for the single segments. Results and conclusion. In 31 of the 35 (88.6%) carriers degenerative change was found in the cervical spine, but only in 8 of the 35 (22.9%) non-carriers (P<0.01). The total score and the scores for segments C4/5, C5/C6 anc C6/C7 were significantly higher for the carriers than the non-carriers. It is concluded that the axial strain of load-carrying on the head exacerbates degenerative change in the cervical spine.     

Sclerotic lesions of the cervical spine in sarcoidosis

Sarcoidosis is a common multisystem disorder characterized by noncaseating epithelial granulomata, with osseous involvement typically seen in 5% of patients. While the lace-like or cystic pattern frequently seen in radiographs of the phalanges is well appreciated, sclerotic lesions of the spine are uncommon. We review a case of sarcoidosis of the cervical spine with sclerotic changes that mimicked blastic metastatic disease.     

Spinal cord magnetic resonance imaging in suspected multiple sclerosis

We examined the value of spinal cord magnetic resonance imaging (MRI) in the diagnostic work-up of multiple sclerosis (MS). Forty patients suspected of having MS were examined within 24 months after the start of symptoms. Disability was assessed, and symptoms were categorized as either brain or spinal cord. Work-up further included cerebrospinal fluid analysis and standard proton-density, T2-, and T1-weighted gadolinium-enhanced brain and spinal cord MRI. Patients were categorized as either clinically definite MS (n = 13), laboratory-supported definite MS (n = 14), or clinically probable MS (n = 4); four patients had clinically probable MS, and in nine MS was suspected. Spinal cord abnormalities were found in 35 of 40 patients (87.5 %), consisting of focal lesions in 31, only diffuse abnormalities in two, and both in two. Asymptomatic spinal cord lesions occurred in six patients. All patients with diffuse spinal cord abnormality had clear spinal cord symptoms and a primary progressive disease course. In clinically definite MS, the inclusion of spinal imaging increased the sensitivity of MRI to 100 %. Seven patients without a definite diagnosis had clinically isolated syndromes involving the spinal cord. Brain MRI was inconclusive, while all had focal spinal cord lesions which explained symptoms and ruled out other causes. Two other patients had atypical brain abnormalities suggesting ischemic/vascular disease. No spinal cord abnormalities were found, and during follow-up MS was ruled out. Spinal cord abnormalities are common in suspected MS, and may occur asymptomatic. Although diagnostic classification is seldom changed, spinal cord imaging increases diagnostic sensitivity of MRI in patients with suspected MS. In addition, patients with primary progressive MS may possibly be earlier diagnosed. Finally, differentiation with atypical lesions may be improved. Received: 21 April 1999; Revised: 3 August 1999; Accepted: 7 August 1999     

Are magnetic resonance flexion views useful in evaluating the cervical spine of patients with rheumatoid arthritis?

Objective. To determine whether MR imaging in flexion adds value relative to imaging in the neutral position with respect to displaying involvement of the subarachnoid space, brainstem and spinal cord. Design and patients. T1-weighted MR images of the cervical spine in 42 rheumatoid arthritis patients with cervical spine involvement were obtained and analyzed prospectively. We assessed changes between images obtained in the neutral position and following active flexion, especially horizontal atlantoaxial and subaxial motion, presence or absence of brainstem compression, subarachnoid space involvement at the atlantoaxial and subaxial level and the cervicomedullary angle. Vertical atlantoaxial subluxation and the amount of pannus were correlated with motion and change in subarachnoid space. Results. The flexion images showed horizontal atlantoaxial motion in 21 patients and subaxial motion in one patient. The flexion view displayed brainstem compression in only one patient. Involvement of the subarachnoid space increased at the atlantoaxial level in eight (19%) patients (P=0.004) and at the level below C2 in five (12%) patients (P=0.03). There were no patients with a normal subarachnoid space in neutral position and compression in the flexed position. The cervicomedullary angle changed significantly with flexion. Vertical atlantoaxial subluxation and the amount of pannus did not show a significant correlation with motion or subarachnoid space involvement. Conclusion. MR imaging in the flexed position shows a statistically significant narrowing of the subarachnoid space at the atlantoaxial level and below C2. Cord compression is only observed on flexion views if the subarachnoid space in neutral position is already decreased. MR imaging in the flexed position might be useful, since subarachnoid space involvement may be an indicator for the development of neurologic dysfunction. Received: 15 June 1999 Revision requested: 29 July 1999, 20 September 1999 Revision received: 2 October 1999 Accepted: 26 October 1999     

Primitive neuroectodermal tumor in a child with tuberous sclerosis

 The case of a 13-year-old boy with tuberous sclerosis and primitive neuroectodermal tumor of bone is presented. A pathogenetic association between these two entities is postulated, the unifying underlying mechanism being a maldevelopment of the neural crest, or neurocristopathy.     

Prevertebral soft tissue swelling following trauma: usefulness following tube placement

Objective. Prevertebral soft tissue swelling (PVSTS) is an important marker of spinal trauma. In patients with missed or occult cervical fractures, it may be the only indication of serious injury. It has been anecdotally suggested that PVSTS is not useful following placement of a nasogastric (NGT) or endotracheal (ETT) tube because of possible iatrogenic trauma and/or soft tissue compression. Consequently, we investigated trauma patients for evidence of PVSTS, comparing radiographs performed before and after placement of NGTs and/or ETTs. Design and patients. PVSTS at the C2 and C6 levels was measured on lateral cervical spine radiographs in 102 patients with cervical spine fractures. Measurements were obtained in 66 patients before and after placement of either an NGT (23), ETT (8), or both an NGT and ETT (35). They were also obtained in 36 control patients with fractures and neither an NGT nor ETT, at presentation and after an interval temporally matched to that in the patients with tubes in place. Results. The group with ETTs showed variable changes to PVSTS (31% increase, 63% decrease, and 6% no change). The group with NGTs also showed variable changes to PVSTS (33% increase, 53% decrease, and 13% no change). The group with ETTs and NGTs similarly showed variable changes to PVSTS (25% increase, 72% decrease, 3% no change). Surprisingly, the control group showed similar temporal changes without tube placement (49% increase, 36% decrease, 13% no change). Analyses using the one-tailed F-test of the ratio of the variance of the tube to non-tube groups and the Mann-Whitney test were performed. No significant difference was found in the prevertebral soft tissues at the C2 level between those with tubes in place and the control subjects. However, at the C6 level there was statistical significance between the groups with NGTs and both NGTs and ETTs versus the non-tube groups. Probability under the F-test for the groups with NGTs and both NGTs and ETTs was 0.001 and 0.005, respectively. Under the Mann-Whitney test, P values for groups with NGTs and both NGTs and ETTs were 0.0002 and 0.0001, respectively. Conclusion. The appearance of PVSTS showed variable and unpredictable changes following ETT, NGT, or combined ETT/NGT placement at the C2 level. This appears to be an artifact of temporal changes. However, at the C6 level, the presence of PVSTS following NGT or ETT and NGT placement (but not ETT placement alone) may be an accurate indirect sign of cervical spine injury. Received: 14 September 1999 Revision requested: 30 December 1999 Revision received: 4 February 2000 Accepted: 8 February 2000     

Improving the cervical spine X-ray in trauma patients utilizing dynamic range compression (DRC) modified digital radiography

Purpose: Inadequate cervical spine X-rays delay diagnosis and treatment and add radiation exposure to trauma patients with suspected cervical spine injury. Digital radiography (DR) with dynamic range compression (DRC) modification can improve the visualization of abnormalities in the cervical spine X-ray. Methods: Two digital hard copy cervical spine X-rays from each of 65 trauma patients were used, both with standard DR processing, and with the second image having the DRC algorithm applied. Blinded readers from emergency medicine, surgery, radiology, and critical care specialties evaluated the films with data analyzed by Student's t-test and ϰ²; P < 0.05. Results: Readers cleared more of the DRC than of the non-DRC images: 41 % vs 30 %, P < 0.001. More vertebral bodies were visualized on DRC than on non-DRC images: 65 % vs 53 % showing C7, P < 0.001. For overall impression of the image quality, DRC images rated higher on a 10-cm visual analog scale than non-DRC: 6.7 vs 4.2, P < 0.001. Conclusions: DRC modification of DR images enabled physicians to evaluate cervical spine X-rays more rapidly and accurately after trauma, requiring fewer repeat films.     

Calcification of the alar ligament of the cervical spine: imaging findings and clinical course

Ligamentous calcification of the cervical spine has been reported in the yellow ligament, anterior and posterior longitudinal ligaments and interspinous ligament. Calcification in the upper cervical spine is rare, although some cases with calcification of the transverse ligament of the atlas have been reported. Two patients with calcification of the alar ligament with an unusual clinical presentation and course are described. Examination by tomography and computed tomography (CT) showed calcification of the alar ligament and the transverse ligament of the atlas. CT documented decreased calcification as symptoms resolved. There may be a role for CT in the search for calcifications in the upper cervical spine in patients presenting with neck pain and pharyngodynia if radiographs are normal. Received: 13 October 2000 Revision requested: 17 November 2000 Revision received: 18 December 2000 Accepted: 19 December 2000     

A new classification for cervical vertebral injuries: influence of CT

Objective. Computed tomography (CT) has been demonstrated to be superior to radiography in identifying cervical vertebral injuries. However, many of these injuries may not be clinically significant, and require only minimal symptomatic and supportive treatment. It is therefore imperative that radiologists and spine surgeons have criteria for distinguishing between those injuries requiring surgical stabilization and those that do not. The authors propose a new classification of cervical vertebral injuries into two categories: major and minor. Design and patients.  A data base, acquired on 1052 separate cervical injuries in 879 patients seen between 1983 and 1998, was reviewed. Four categories of injury based on mechanism [hyperflexion (four variants), hyperextension (two variants), rotary (two variants), and axial compression (five variants)] were identified. ”Major” injuries are defined as having either radiographic or CT evidence of instability with or without associated localized or central neurologic findings, or have the potential to produce the latter. ”Minor” injuries have no radiographic and/or CT evidence of instability, are not associated with neurologic findings, and have no potential to cause the latter. Results and conclusions.  Cervical injury should be classified as ”major” if the following radiographic and/or CT criteria are present: displacement of more than 2 mm in any plane, wide vertebral body in any plane, wide interspinous/interlaminar space, wide facet joints, disrupted posterior vertebral body line, wide disc space, vertebral burst, locked or perched facets (unilateral or bilateral), ”hanged man” fracture of C2, dens fracture, and type III occipital condyle fracture. All other types of fractures may be considered ”minor”. Received: 22 July 1999 Revision requested: 7 October 1999 Revision received: 21 December 1999 Accepted: 30 December 1999     

Helical CT in the primary trauma evaluation of the cervical spine: an evidence-based approach

This review provides a summary of the cost-effectiveness, clinical utility, performance, and interpretation of screening helical cervical spine CT for trauma patients. Recent evidence supports the use of helical CT as a cost-effective method for screening the cervical spine in high-risk trauma patients. Screening cervical spine CT can be performed at the time of head CT to lower the cost of the evaluation, and when all short- and long-term costs are considered, CT may actually save money when compared with traditional radiographic screening. In addition to having higher sensitivity and specificity for cervical spine injury, CT screening also allows more rapid radiological clearance of the cervical spine than radiography. Patients who are involved in high-energy trauma, who sustain head injury, or who have neurological deficits are candidates for CT screening. Screening with CT may enhance detection of other potentially important injuries of the cervical region. Received: 17 March Revision requested: 14 April 2000 Revision received: 19 July 2000 Accepted: 19 July 2000     

Should an MR scan be performed routinely after a normal clearance CT scan in the trauma patient? Experience with 59 cases

Magnetic resonance (MR) imaging is not routinely used to exclude ligamentous and other soft tissue injury in the unconscious trauma patient. In order to determine the frequency and types of soft tissue injuries detected by MR imaging but not by computed tomography (CT), we performed a retrospective investigation comparing the MR findings in 59 trauma patients, either alert or unconscious, who previously had undergone a negative clearance multislice CT study of the cervical spine. Six patients had abnormalities not identified on the CT studies, including four cases of ligamentous injury.     

Intraosseous glomus tumor of the fibula

Glomus tumor is a rare, benign vascular tumor and intraosseous glomus tumor, which arises primarily within bone, is even rarer. Fewer than 20 cases have been reported in the literature. We present the case of a 34-year-old woman with glomus tumor primarily in the midshaft of the fibula that radiologically mimicked chondromyxoid fibroma, aneurysmal bone cyst or adamantinoma, together with a review of other reported cases. Received: 5 July 2000 Revision requested: 10 August 2000 Revision received: 28 August 2000 Accepted: 28 August 2000     

Mucoid degeneration of the anterior cruciate ligament mistaken for ligamentous tears

Objective. To describe the MR features of mucoid degeneration of the anterior cruciate ligament (ACL) in a series of patients with MRI findings that were mistaken for tears in the majority of cases but who were found to have an intact ligament at arthroscopy. We will suggest a pathologic entity corresponding to this finding and describe some characteristic features that can be used to identify this entity on MRI. Design. A retrospective analysis of 10 MRI examinations of the knee was performed after arthroscopic evaluation. Prearthroscopic MRI findings had been interpreted as a tear in six patients prospectively and in the remaining four the diagnosis of mucoid degeneration was suggested and ultimately proven. All patients had an intact ACL by preoperative clinical examination, examination under anesthesia, and at arthroscopy. Results. MRI examinations demonstrated an ill-defined ACL, greater in girth than the normal ligament and characterized by increased signal on all sequences. The high-signal ligament was oriented in the normal direction of the ACL. The overall appearance of the ligament was retrospectively described as like a celery stalk. Arthroscopy demonstrated mechanically intact ligaments with a normal to expanded external appearance. Probing of three of the ligaments caused a material to be expressed and pathologic evaluation resulted in the diagnosis of cystic, mucoid degeneration. Conclusion. Mucoid degeneration and an intact ACL can be suspected when an apparently thickened and ill-defined ligament with increased signal intensity on all sequences is identified in a patient with a clinically intact ligament. Received: 10 April 2000 Revision requested: 18 July 2000 Revision received: 13 November 2000 Accepted: 27 November 2000     

Relationship of elongated anterior tubercle to incomplete segmentation in the cervical spine

 Purpose. To describe the elongated anterior tubercle of cervical vertebrae, its association with incomplete segmentation, and its analogy to sacralization of the lower lumbar vertebrae. Materials and methods. Cases with elongated anterior tubercles of the cervical vertebrae detected on plain radiography were collected during routine practice and their features analyzed on plain radiography and MR imaging. Five patients, aged 19–40 years, with the anomaly seen on plain radiography were included in this study. MR imaging was undertaken in one patient. Results. Hypertrophy of the anterior tubercle was associated with incomplete segmentation in three of the five patients. Oblique views were adequate to demonstrate its nature. Conclusions. The association of an elongated tubercle and incomplete segmentation is similar to partial sacralization at the lumbosacral junction. Clinically it is important that these anomalies are not mistaken for pathologic findings.     

MRI of fractures of the distal radius: comparison with conventional radiographs

Objective. To compare the evaluation of fractures of the distal radius with MRI and conventional radiographs. To demonstrate the ability of MRI to detect unsuspected soft tissue derangement accompanying this common injury. Design and patients. Twenty-one consecutive inpatients admitted following fracture of the distal radius underwent preoperative evaluation with both conventional radiographs and MRI. In each case, analysis was made of both the osseous and soft tissue injury. MRI findings were compared with those identified on conventional radiographs and at subsequent surgical fixation. Results. Of 21 patients with fractures of the distal radius, 20 had extension to the radiocarpal articulation, 14 had distal radio-ulnar joint extension and 5 had avulsion of the ulnar styloid.Occult carpal bone fractures accompanying fracture of the distal radius were identified in two patients: one of the capitate and the other of the second metacarpal base. Ten patients (48%) had associated soft tissue injury: six patients had scapholunate ligament rupture, two patients had disruption of the triangular fibrocartilage, one patient had extensor carpi ulnaris tenosynovitis and one patient had a tear of a dorsal radiocarpal ligament. Of five patients with ulnar styloid avulsions, none had evidence of triangular fibrocartilage tears. Conclusion. MRI affords better evaluation of osseous injury accompanying distal radial fractures than conventional radiographs. Intra-articular soft tissue injury accompanies distal radial fractures in almost 50% of cases. Scapholunate ligament disruption commonly accompanies intra-articular fracture through the lunate facet of the distal radius. Fracture of the ulnar styloid is infrequently associated with tear of the triangular fibrocartilage.     

MRI of pediatric growth plate injury: correlation with plain film radiographs and clinical outcome

Purpose. To evaluate pediatric growth plate injuries with conventional radiographs and magnetic resonance imaging (MRI). To review potential clinical impact of MRI on subsequent patient management and outcome. Methods. Fourteen patients with known or suspected growth plate injury were studied. Each patient underwent imaging by conventional radiography and MRI within 2 weeks of injury. Findings on conventional radiographs and on MR images were compared and then correlated with subsequent management and outcome at a mean of 12 months. Results. Direct visualization of cartilage afforded by MRI improved evaluation of growth plate injury in each case. MRI changed Salter Harris classification or staging in 2 of 9 patients with fractures visualized on conventional radiographs, allowed the detection of radiographically occult fractures in 5 of 14 cases, and resulted in a physical change in management in 5 of the 14 patients studied. Conclusion. MRI has an important role in the evaluation of acute pediatric growth plate injury, particularly when diagnostic uncertainty persists following the evaluation of conventional radiographs. MRI allows detection of occult fractures, may alter Salter Harris staging, and in the reported study it frequently resulted in a change in patient management.     

Imaging of compressive vertebral haemangiomas

Compressive vertebral haemangiomas (VHs) are rare. Correct preoperative diagnosis is useful both for operative planning (since compressive VHs are extremely vascular lesions) and to allow preoperative embolisation. Numerous radiological signs for VHs have been described, but compressive VHs frequently have atypical features. In particular, magnetic resonance features are not well established. We present imaging features in three cases of compressive VH and review the imaging findings in an additional 106 previously published cases. Findings were typical in 52 of 80 plain film (65 %), 33 of 41 computed tomography (80 %) and 13 of 25 magnetic resonance examinations (52 %). The prevalence of previously described imaging features is reported. Awareness of the range of magnetic resonance features is important since this is frequently the initial investigation in patients presenting with symptoms of neural compression. Since computed tomography is typical in 80 % of cases, this is a useful confirmatory test if magnetic resonance features are suspicious but not diagnostic of compressive VH. Received: 6 August 1999; Revised: 4 November 1999; Accepted: 4 November 1999     

CT scan patterns of articular mass injuries of the lower cervical spine

Traumatic lesions of the cervical articular mass are infrequent, are potentially unstable and often require internal fixation. Standard X-rays and CT images can be difficult to analyze in an emergency situation. Standard X-rays must always be performed first, but CT, particularly helical CT, is the definitive imaging modality. Two-dimensional reformations are performed in all cases, together with 3-D reformations when indicated. We here present a simple and logical analysis based on the normal pattern of the interfacetal joint, which is always made of two pieces of bone, and only two, in a precise order. Post-traumatic deviations from this normal pattern reflect an injury, and there exists an accurate correlation between the CT pattern and the pathologic features.