Rheumatoid arthritis in the cervical spine

Rheumatoid arthritis causes synovitis in the cervical spine and injures skeletal structures at any level. Subluxations occur with pain and spinal cord dysfunction. Subluxations are common; neurological problems are less so, but death from subluxations is not common. However, once myelopathy is established, the natural history is poor. Advances in radiologic imaging through computed tomography and magnetic resonance imaging greatly assist anatomic assessment. Neurologic deterioration and pain are indications for surgery. Preoperative skeletal traction is often required to align the spine, and fusion techniques are used for stabilization.     

Metastatic disease of the spine.

Advances in imaging studies and techniques of spinal stabilization permit improved surgical treatment of patients with metastatic disease of the spine. Preoperative evaluation, selection of patients for operative management, and results of published clinical series are reviewed. Surgical approaches for optimal tumor excision, neural decompression, and spinal stabilization are discussed.     

Aktuelle bildgebende Diagnostik der Wirbelsäulenerkrankungen

Imaging of the spine is an essential prerequisite in the clinical workup of spine disease. Conventional radiography (CR) is still used as a basic diagnostic tool and enables an initial diagnosis to clarify symptomatology. Advanced cross-sectional techniques such as magnetic resonance imaging and computed tomography enable a dedicated diagnostic workup only of complex spinal pathologies. Due to its enormous innovation and broad availability, multidetector computed tomography could replace spinal CR in the diagnostic workup of acute and multiply injured patients. Nuclear medicine bone scans and positron emission tomography serve as screening studies and are an adjunct to morphologic radiological imaging. This review article summarizes the radiological and nuclear medicine imaging modalities and their diagnostic and therapeutic significance for diagnostic workup of common spinal disorders.     

Radiofrequenzablation bei Osteoidosteomen der Wirbels?ule

Osteoid osteoma was first described by Jaffe in 1935 as a benign bone neoplasm mainly located in the diaphyseal areas of long bones: 10% are located in the spine, mainly in the lumbar and thoracic posterior elements. Therapy is required due to nocturnal pain independent of the physical load and responds especially well to anti-inflammatory drugs due to the excessive production of prostaglandins in the nidus. Diagnosis is confirmed by multi-slice computed tomography (CT), magnetic resonance imaging (MRI) and skeletal scintigraphy scans. In cases with typical symptoms and imaging, open biopsies are rarely needed. Although CT-guided radiofrequency ablation is accepted as the gold standard treatment option for osteoid osteoma in the extremities, this technique is limited in spinal applications due to the risk of thermal damage to adjacent neurovascular structures. Technical advances in the administration of radiofrequency ablation have, however, resulted in new and expanded indications in the spine so that the necessity for open surgical excision of spinal osteoid osteoma is becoming less.     

Imaging intervertebral disc degeneration

Magnetic resonance imaging provides excellent anatomic detail of spinal tissues, but fails to provide the type of information that permits a definitive diagnosis in many patients with back pain. New imaging strategies that can be applied to the study of intervertebral disc degeneration include diffusion-weighted imaging, magnetic resonance imaging, diffusion tensor imaging, magnetic resonance spectroscopy, functional magnetic resonance imaging, dynamic computed tomography and magnetic resonance imaging, and T2 relaxometry. With dynamic imaging, the relative motions of normal and degenerated lumbar motion segments can be evaluated noninvasively. With further evaluation of the technique, hypermobile segments may be distinguishable from those with normal relative motion. T2 measurements obtained by T2 relaxometry appear to have important advantages with regard to spinal imaging because this modality provides a continuous and objective measure of the content of free water in the disc, which decreases with aging and degeneration. Anatomic imaging of the spine is highly accurate in the evaluation of nonmechanical causes of back pain and less beneficial in the evaluation of back pain that is due to mechanical causes. The development of functional imaging strategies of the spine will likely improve the management of patients with back pain. This article outlines the current magnetic resonance imaging protocols for intervertebral disc degeneration, indicates deficiencies in current imaging, and describes functional imaging strategies for the spine that will likely improve the evaluation of patients with back pain. It also reviews recent published articles on magnetic resonance imaging and computed tomographic imaging of the spine and details the results of studies that have explored the future potential of spine imaging.     

Efficacy of magnetic resonance imaging in the evaluation of posterior cervical spine fractures

STUDY DESIGN: A retrospective study using two independent, blinded musculoskeletal radiologists to evaluate the sensitivity, specificity, and predictive value of cervical spine magnetic resonance imaging in detecting posterior element fractures of the cervical spine. OBJECTIVE: To evaluate the sensitivity, specificity, and predictive value of magnetic resonance imaging, using computed tomographic scanning as the gold standard, in the diagnosis of posterior element cervical spine fractures. SUMMARY OF BACKGROUND DATA: Few investigators have evaluated the accuracy of magnetic resonance imaging in the determination of cervical spine fractures. METHODS: From January 1994 through June 1996, 75 cervical spine fractures in 32 patients were confirmed by computed tomography. Two musculoskeletal radiologists who were blinded to the clinical history and presence or absence of cervical injury among the study population, independently evaluated each cervical magnetic resonance image recording the presence or absence of soft tissue or bony injury. RESULTS: The overall sensitivity and specificity rates for the diagnosis of a posterior element fracture by magnetic resonance imaging was 11.5% and 97.0%, respectively. The positive predictive value for this group was 83%, and the negative predictive value was 46%. In reference to anterior fractures, the sensitivity was 36.7% and the specificity 98%. Positive and negative predictive values were 91.2% and 64%, respectively. CONCLUSIONS: Magnetic resonance imaging was not effective in recognizing bony injury to the cervical spine and in particular was not as sensitive or as specific as computed tomography in identifying cervical spinal fractures. Computed tomography remains the study of choice for the detection and precise classification of bony injuries to the cervical region, especially when plain radiographs are difficult to evaluate. Magnetic resonance imaging, although not as effective as computed tomography in defining specific bony disorders, remains the gold standard in the evaluation of spinal cord injury, occult vascular injury, and intervertebral disc disruption (hyperextension injury), including herniation and other soft tissue disorders (hematoma, ligament tear).     

Benigne und semimaligne Tumoren der Wirbelsäule

Diagnostic radiology and magnetic resonance imaging (MRI) are the most important imaging tools in the evaluation of benign bone tumors. Computed tomography (CT) is an additional tool for bony lesions, such as in cases of confirmation of the diagnosis of osteoid osteomas. For benign bony lesions three-stage skeletal scintigraphy is an optional additional diagnostic tool. The identification of benign or semimalignant bone tumors is not always clear; therefore percutaneous biopsy is necessary in most cases. In benign spinal tumors an intralesional curettage with reconstruction and stabilization is sufficient. In cases of semimalignant tumors, e.g. giant cell tumors localized in the spine, an en bloc resection is necessary because of the high recurrence rate.     

Spinal neurenteric cyst in association with syringomyelia: case report.

A case of spinal neurenteric cyst in association with Klippel-Feil deformity, spinal lipoma, and syringomyelia is presented. Neuroradiological evaluation was performed by means of magnetic resonance imaging of the spine and a computed tomography myelograph. The diagnosis of neurenteric cyst was established by histological and immunohistochemical studies. The pathogenesis of syringomyelia associated with an extramedullary mass lesion is discussed.     

Chondrosarcoma of the spine

Twenty patients were diagnosed as having chondrosarcoma of bone that originated in the spine and, except for one, were treated surgically at the Mayo Clinic. The patients' ages ranged from eighteen to seventy years. Pain in the area of involvement was the first symptom in nearly all patients. Nearly one-half of the patients had detected a mass before being diagnosed. In addition, nine patients had neurological symptoms and signs when they were first seen. All patients had a surgical biopsy of the lesion, often combined with decompressive laminectomy. Five patients received postoperative radiation therapy in various dosages. No patient received adjunctive chemotherapy. All but five patients died of local progression of the disease. The five-year survival rate was 55 per cent. The median length of survival was six years. Although it is rare, chondrosarcoma of the spine can usually be identified on radiographs. Preoperative assessment must include computed tomography, magnetic resonance imaging, and, possibly, arteriography to assess the precise extent of the disease. Although surgical ablation often is technically difficult, a wide excision should be attempted. If this is not obtainable, postoperative radiation therapy should be considered.     

Pitfalls of spinal deformities associated with neurofibromatosis in children

A study of 116 patients younger than 12 years of age conclusively diagnosed as having neurofibromatosis was undertaken to determine the incidence of significant orthopedic problems. Deformities of the spine comprised the most common skeletal problem. Seventy-four patients (64%) had spinal deformities. Forty-six patients were treated by posterior spinal fusion. Ten required exploration for pseudarthrosis; six were found to have pseudarthrotic defects in the fusion mass. Eight patients had more kyphosis than scoliosis. Only three patients with kyphoscoliosis obtained a solid posterior spinal fusion after multiple surgical procedures. Anteroposterior and lateral roentgenograms of the cervical spine are recommended at the time of initial evaluation of all spinal deformities. Four patients had severe cervical spine deformities, only one of whom was initially identified as having a cervical spine disorder while under treatment for scoliosis. Three of these patients were seen by other surgical services for neck masses. Following removal of posterior elements, the osseous structures were unstable. Only one patient developed spondylolisthesis. Because of the exceedingly high incidence of pseudarthrosis and spinal instability following attempts at spinal fusion, certain guidelines have evolved for the management of these deformities. High-volume computed tomographic myelography in the prone, lateral, and supine positions or magnetic resonance imaging should be performed on all patients prior to surgical treatment. Anterior disc excision and bone graft followed by posterior arthrodesis with instrumentation are indicated if the kyphotic angle is greater than 50 degrees or if scoliosis is greater than 80 degrees. Even combined anterior and posterior arthrodesis operations did not guarantee successful permanent spinal stability in young patients with neurofibromatosis.     

Disruption of the thoracic spinal cord with unilateral ligament damage and no spine fracture

We report a case of total spinal cord disruption confirmed surgically. The spinal cord injury resulted from a traumatic event involving the thoracic spine which did not provoke any bone lesion. The patient presented joint injury and unilateral ligament damage. No spinal fracture was observed. In patients with neurological signs, the imaging work-up should associate CT-scan and magnetic resonance imaging to obtain a complete study of the bone and joint structures as well as the ligaments and the spinal cord.     

Spinal cord compression by a unifocal eosinophilic granuloma: a case report of an adult with unusual roentgenological features

We describe an unusual case of unifocal eosinophilic granuloma of the spine in a 38-year-old woman who presented with spinal cord compression. After 2 years of back pain, x-ray films of the spine were normal, but computed tomography and magnetic resonance imaging demonstrated a lytic lesion of the 1st lumbar vertebral body with cephalic extension in the epidural space. The lesion was later confirmed at operation to be an eosinophilic granuloma spreading into the surrounding tissues.     

Percutaneous computed-tomography-guided biopsy of the thoracic and lumbar spine

Axial computed tomographic scans were used to guide percutaneous needle biopsies in 76 patients with thoracic and lumbar spinal lesions. Prebiopsy evaluation included spine radiographs, radionuclide bone scans, computed tomographic scans, magnetic resonance imaging scans in some cases, and coagulation studies. Forty-five patients were diagnosed as having metastatic lesions, 11 infection, and 12 primary bone tumors. Of all patients, 34 had lytic vertebral lesions with significant collapse and questionable spinal stability. Six of those had a concomitant paravertebral mass. A clinical and pathologic correlation was completed for each of the cases studied. Histologic diagnosis confirming the clinical suspicion was obtained on the first biopsy attempt in 65 (86%) of the 76 cases.     

Neurenteric cyst: surgery and diagnostic imaging

Neurenteric cysts are rare, with fewer than 30 cases noted in the literature. We report the case of a newborn infant with respiratory distress caused by a large neurenteric cyst that was identified by prenatal ultrasound. Treatment consisted of excision of the mass through a right posterolateral thoracotomy. The cyst adhered to the spine at the level of the first thoracic vertebra and communicated with the jejunum through a posterior diaphragmatic defect. Postoperative studies with magnetic resonance imaging (MRI) and computed tomography (CT) disclosed an anterior meningocele and tethering of the spinal column. This is the second reported case of a neurenteric cyst demonstrated by prenatal ultrasound. The presence of an intrathoracic cyst associated with spinal abnormalities is characteristic of this anomaly. With imaging techniques such as MRI and CT, we may detect residual intraspinal disease associated with neurenteric cysts.     

Computed tomography and magnetic resonance imaging in spinal hydatidosis

Computed tomography and magnetic resonance imaging in patients with spinal hydatidosis provide comprehensive evaluation of the actual extent of the disease. Paravertebral uncalcified cysts, hardly recognizable by conventional radiologic examinations, are clearly shown by both methods. Initial involvement of the spongy bone is evident in computed tomography scans, in contrast to what usually appears to be normal in plain films or tomograms. Occurrence of cysts within the spinal canal is revealed by both types of computed scans, with magnetic resonance imaging being able to provide further information on the involvement of the spinal cord.     

Vertebral artery occlusion after acute cervical spine trauma

STUDY DESIGN: A retrospective study of vertebral artery injury diagnosed during the last 6 years in our institution. OBJECTIVES: To determine the clinical and radiologic features of vertebral artery injury. SUMMARY OF BACKGROUND DATA: Extracranial occlusion of the vertebral artery associated with cervical spine fracture is uncommon and can cause serious and even fatal neurologic deficit due to back lifting and cerebellar infarction. Magnetic resonance imaging and magnetic resonance angiography are extremely helpful in the examination of acute injuries of the cervical spine. METHODS: Magnetic resonance imaging and magnetic resonance angiography were performed at the time of injury. RESULTS: The authors reviewed six patients with cervical spine fractures who were diagnosed with a unilateral occlusion of the vertebral artery by means of magnetic resonance imaging/magnetic resonance angiography. One patient had signs of vertebrobasilar insufficiency and another with complete cord lesion had cerebellar and back lifting infarctions. Surgical anterior spinal fusion was performed in five patients, and one was treated by traction and orthosis. At the time of discharge, five patients had no vertebrobasilar symptoms, and the patient who experienced vertebrobasilar territory infarctions showed no progression of the neurologic damage. CONCLUSIONS: Vertebral artery injury should be suspected in cervical trauma patients with facet joint dislocation or transverse foramen fracture. Magnetic resonance imaging/magnetic resonance angiography is a helpful test to rule out vascular injury. Vertebral artery injury affects the extracranial segment at the same level as the cervical fracture. This is a retrospective review that did not permit drawing conclusions about the effects of early surgical stabilization in the treatment of cervical spine injuries with associated vertebral artery injury; however, surgical stabilization may avoid propagation and embolization of the clot located at the site of the lesion.     

Back pain caused by benign tumors and tumor-like lesions of the thoracolumbar spine

Twenty-two patients with benign tumors or tumor-like lesions of the spine (vertebral echinococcal cysts, eosinophilic granuloma) presented with back pain and deformity. The duration of pain ranged from 1 to 6 years. Five patients had incomplete paraplegia at admission. Spine deformity was observed in patients with osteoid osteoma, osteoblastoma, hemangioma, and vertebral echinococcal involvement. All patients underwent clinical evaluation, laboratory studies, and histologic studies. Electromyogram studies were performed in patients who had a neurologic deficit or nerve root irritation. Imaging evaluation consisted of plain films, bone scans, computed tomography scans, and magnetic resonance imaging scans. Fifteen patients had lumbar involvement; 7 had thoracic involvement. For 18 patients, management included tumor excision and thorough debridement of the lesion. Spinal instrumentation and fusion were used to correct the deformity and treat the instability in 5 patients. Patients were followed for 1 to 8 years. Of the 5 patients with incomplete paraplegia, 4 recovered completely, and the fifth (who had spinal cord hemangioma) improved 2 grades on Frankel's scale. The remaining patients were disease free and returned to routine daily activities. Benign tumors or tumor-like lesions of the thoracolumbar or lumbar spine are very rare and easily misdiagnosed in patients with persistent back pain. Patients whose symptoms progress or fail to respond over an appropriate period of time should be evaluated further. Complete excision of the tumor followed by spinal instrumentation in the presence of deformity or instability is the treatment of choice.     

Magnetic resonance imaging after pedicular screw fixation of the spine.

Magnetic resonance imaging (MRI) of the thoracolumbar spine is valuable in the diagnosis of acute and chronic spine injuries. It allows evaluation of the nerve roots, spinal cord, and the supporting bony and ligamentous structures. Magnetic resonance imaging can be used to detect sequelae of spinal cord injury and any mechanical impingement on the spinal cord or nerve roots. Pedicular screw fixation of the spine is becoming the procedure of choice for stabilization of the lumbar spine, yet it limits the postoperative use of MRI because of marked imaging artifacts arising from the ferromagnetic properties of the used stainless steel implants. The authors have compared extensive artifacts produced by the stainless steel implants with those produced by titanium implants. Titanium implants produced fewer artifacts in the spinal canal. The use of MRI compatible materials in thoracolumbar spine stabilization would permit detailed examinations by serial MR imaging.     

Chronic myelopathy due to a giant spinal arachnoid cyst: a complication of the intrathecal injection of phenol. Case report

Acquired intradural arachnoid cystic lesions of the spine have been associated with trauma, hemorrhage, parasitic infections, and other insults that cause inflammation and subarachnoid adhesions. The authors describe the case of a previously healthy 36-year-old woman who presented with a chronic myelopathy due to the progressive development of a giant spinal arachnoid cyst that resulted after the intrathecal injection of phenol for the management of chronic upper extremity pain. Neurological examination, spinal computed tomography, and magnetic resonance imaging were used for diagnostic and follow-up purposes. Even after the initial excision of the cyst, the patient remained symptomatic with minimal functional recovery.     

Magnetic resonance artifact in the postoperative cervical spine. A potential pitfall

An magnetic resonance imaging artifact that stimulates hypertrophic bone formation is described in patients who have had an anterior cervical discectomy. The magnetic resonance images of 26 patients with anterior cervical discectomy were retrospectively reviewed. Comparison was made to the available concurrent computed tomographic scans, computed tomographic myelograms, and operative reports. A bovine spine was drilled with a drill only at one level and with a metal suction tip in close proximity to the drill at another level, and magnetic resonance images were obtained. Artifact was present in 12 patients and absent in 14; this was confirmed in the 8 patients with comparison studies. Close correlation was seen with the prospective reading of the presence of artifact and operative drill use in the seven patients with available operative reports. The bovine spine model showed no artifact at the drill-only level and significant artifact at the level where the metal suction tip was positioned next to the drill. Small metal flecks were seen grossly at the second level, but not on plain roentgenograms. The metallic magnetic resonance artifact seen in postoperative cervical spines is probably from small bits of metal from the metal suction tip as it occasionally hits the drill. Bone abnormalities seen on magnetic resonance imaging at the level of a previous anterior cervical discectomy may need a cervical computed tomogram to confirm the findings.