Radiology

Diagnosis: Osteolytic metastatic carcinoma of the left L-3 pedicle and vertebral body. This is the "one-eyed pedicle" sign or the "winking owl sign" of lytic metastatic disease.
(Figure 1)

Table 1. Radiologic Features
of Spinal Metastasis

LOCATION:v Lumbar/thoracic spine v Vertebral body, pedicles

SIGNS: Altered bone densityv Decreased: moth-eaten, permeative diffusev Increased: localized, ivory vertebra Cortical destruction Disc space unaffected Pathologic collapse v Decreased posterior vertebral body heightv Endplate disruption (malignant Schmorl’s node) Pedicle destructionv One-eyed pedicle sign (winking owl sign)

v Blind vertebra (both pedicles destroyed

DISCUSSION: Pedicle. The pedicle is an important radiologically detectable site for osteolytic metastatic carcinoma. Any component of the neural arch can be involved, although the pedicle is by far the most common location. Destruction of the posterior vertebral body with contiguous involvement of the pedicle attachment results in loss of the cortical outline of the pedicle.¹ This has been referred to as the one-eyed pedicle sign or the winking owl sign and is most commonly found in the lower thoracic and lumbar spine. It is most easily visualized on the AP radiograph. Most cases of pedicle destruction involve a single vertebra; however, multiple levels can be affected. Occasionally, bilateral pedicular destruction may occur and is referred to as the blind vertebra. (Table 1)

The most common cause for a missing pedicle is osteolytic metastatic carcinoma; however, agenesis of a pedicle may also occur. The key to radiologic differentiation is to search for a stress-related reactive sclerosis and enlargement of the contralateral pedicle. If this sign is present, it represents a firm assurance that osteolytic metastatic carcinoma is not present. Those cases of agenesis of the pedicle that create no stress hypertrophy of the opposite pedicle must be considered metastatic tumors until proven otherwise. Previous radiographs in this circumstance will be very helpful. Destruction of a pedicle in a patient under the age of thirty years is most commonly due to aneurysmal bone cyst (ABC), osteoblastoma, neurofibroma, or other cord tumors.

Dr. Terry R. Yochum is a second generation chiropractor and a Cum Laude Graduate of National College of Chiropractic, where he subsequently completed his radiology residency. He is currently Director of the Rocky Mountain Chiropractic Radiological Center in Denver, Colorado, and Adjunct Professor of Radiology at the Southern California University of Health Sciences, as well as an instructor of skeletal radiology at the University of Colorado School of Medicine, Denver, CO. Dr. Yochum can be reached at 1-303-940-9400 or by e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Dr. Chad J. Maola is a 1990 Magna Cum Laude Graduate of National College of Chiropractic. Dr. Maola is a Chiropractic Orthopedist and is available for post-graduate seminars. He may be reached at 1-303-690-8503 or e-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Reference

1. Yochum TR, Rowe LJ: The Essentials of Skeletal Radiology, 3rd ed.,

Baltimore, Williams & Wilkins, 2005.

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Tourette Syndrome and Chiropractic Care

Radiology
Written by Lisa Brittain, D.C., B.S.
Thursday, 23 September 2010 13:25
Tourette Syndrome and Chiropractic Care by Lisa Brittain, D.C., B.S. History and Presenting Symptoms The patient is an 11-year-old male who was diagnosed at the age of four with Tourette syndrome. He has complex vocal and motor tics, which are made worse by stress. The tics affect his daily life; school, sports and his self esteem. The patient also notices he has fatigue and irritability. The patient has been on many different medications—clonidine, inversine, depakote, orap, clarinex, and singular—several causing side effects but never alleviating his tics. Exam Findings The patient is a very active young man; he plays golf, basketball, football, and baseball, as well as excelling at school. He has a good diet. Postural examination revealed anterior head carriage. Motion Palpation found a decrease in range of motion of the cervical spine along with tender spots at C1 and C2. An increase in muscle spasm throughout the right side of the thoracic spine, due to a side bend tic was noted. Surface EMG along with a Rolling Thermal Scan were performed. The sEMG revealed large amounts of nervous system disturbances at C1, C3, C5, C7, T1, T2, T4, T6, T8, T10, T12, L1 and L3. The Rolling Thermal Scan only showed one area of disturbance at T1. Imaging AP and Lateral cervical spine X-rays were performed and revealed a slight decrease in the cervical lordotic curve. Severe rotation and lateral fl exion of C2, along with lateral fl exion of the atlas, were also noted. Clinical Impression Cervical and thoracic segmental joint dysfunctions with associated myospasm in thoracic spine were present. Treatment Plan Diversifi ed adjustments were used to correct the subluxations. Bilateral pisiform adjustments were used to address the thoracic spine; side posture with specifi c contact was used to correct the lumbar spine. For the cervical spine, master cervical was used and a seated occiput adjustment was used to correct the occipital subluxation. The patient was adjusted three times a week for four weeks then re-evaluated. Response to Care The patient tolerated the adjustments very well. During the course of treatment, the patient stopped all of his medications. At the beginning of care, the patient rated his tics, both motor and vocal, an eight out of ten in severity; after twelve treatments, the patient rated his vocal tics a two out of ten and a three out of ten for motor tics. Also the patient noticed he had less fatigue and less irritability, since starting his chiropractic treatments Discussion The chiropractic adjustment relieved pressure that was being put on the nerves in the cervical spine which has direct relation to the brain and nervous system. In this case, the chiropractic treatments were the only thing that relieved the patient from his symptoms, allowing him to be medication free and back to his normal self. Dr. Lisa Brittain graduated from Cleveland Chiropractic College in August 2006. That is where she met her husband, Jacob, who is also a Chiropractor. They opened their own practice in Overland Park. Dr. Brittain can be contacted at offi ce # 913-825-3900, cell # 913-269-1625. Offi ce address 10841 W. 87th Suite 200, Overland Park, KS 66214. Home 950 E. 126th Terr Olathe, KS 66061 Comments (1)

Rasterstereography: Radiation - Free Technology for the Analysis of the Spine and Pelvis

Radiology
Written by Jean Pierre Gibeault, P: eng.
Thursday, 23 September 2010 13:23
Rasterstereography: Radiation - Free Technology for the Analysis of the Spine and Pelvis by Jean Pierre Gibeault, P: eng. RECENTLY IN THE LITERATURE: In a recent study, researchers demonstrated an excellent correlation between X-ray measurements and measurements made with rasterstereography (Schulte 2008). Schulte, et al., produced rasterstereographs and compared them to digitized A-P radiographs of the same 16 patients with idiopathic scoliosis. In this longitudinal study design, with a mean follow-up period of 8 years (range 3 to 10 yrs.), lateral vertebral deviation and vertebral rotation were measured between C7 and L4. This study design mimics actual clinical environments and, therefore, provides invaluable data to the clinician. During the 10 year time frame, Cobb angle measurements increased on average by 13 degrees. The study showed an excellent correlation between rasterstereographic and radiographic progression. The mean difference between rasterstereographs and radiographs was 3.21 mm for lateral vertebral deviation and 2.45 degrees for vertebral rotation. In conclusion, using the parameters of lateral vertebral deviation and vertebral rotation, rasterstereography accurately refl ects the radiograph measured progression of idiopathic scoliosis during the long-term follow-up. The authors do comment that the parameters used are not directly comparable with the Cobb angle. However, they recommend a rasterstereographic examination every 3 to 6 months and a radiographic examination every 12 to 18 months, provided that rasterstereography does not show rapid deterioration of the scoliosis. If this result is reproducible, patients and practitioners alike will want to change the way conditions, such as scoliosis and other global postural distortions are managed. Further studies confi rming the high accuracy of this technology can be found on both normal populations (Hackenberg 2003), as well as those with rotational scoliosis (Drerup 1997). With respect to these studies, it is reasonable to say, rasterstereographs can signifi - cantly reduce the amount of X-rays needed, without sacrifi cing clinical data. In fact, the sophistication of rasterstereography today affords the practitioner a cornucopia of postural information, well beyond what is possible with plain fi lm projections alone. Of course, X-rays do provide unique information about bone and soft-tissue that cannot be gleaned from any other source and, because of this, I believe that both will be a necessary part of chiropractic practice in the future. The Diers Formetric produces the rasterstereographs using an optical light scanner and computer software which automatically fi nds anatomical landmarks without markers or user placement. Thousands of images are taken over an adjustable time frame, which provides information for the quantifi cation of sway patterns, breathing tendencies, weight distribution, and a 3-D computer generated representation of the spine and pelvis. Although not as breakthrough, rasterstereography equipment available in the United States also offers range of motion analysis, cervical spine imaging, and a dynamic forceplate which can invert, dorsifl ex, plantarfl ex and elevate one foot at a time. This is particularly useful when assessing the effects of an orthotic or shoe lift on pelvic and spinal alignment. Rasterstereography is not new; Stokes and Moreland utilized the same technology twenty years ago (Stokes, et al., 1987) when they evaluated for changes in rib hump in seated, standing and forward bending postures. Add new comment

A New Look at Adolescent Idiopathic Scoliosis

Radiology
Written by Mark Sanna, D.C.
Thursday, 23 September 2010 13:17
A New Look at Adolescent Idiopathic Scoliosis by Mark Sanna, D.C. Scoliosis comes from the Greek word skoliosis which means crookedness. Adolescent Idiopathic Scoliosis (AIS) is a deformity of the spinal column with an onset between the ages of ten and eighteen. Most types of scoliosis are classified as idiopathic, meaning that the reasons for this type of deformity of the spine are unknown. Many assumptions concerning the causative factors for the dysfunction have developed. These include: birth trauma, visceral tensions, psychological problems, unilateral shortening of the psoas muscle, nutrition, genetic factors, and so on. Read more... Add new comment

Soft Tissue Neoplasm or Hematoma?

Radiology
Written by Dr. Terry R. Yochum, D.C.; D.A.C.B.R.; Fellow, A.C.C.R. and Dr. Chad J. Maola, D.C.
Wednesday, 22 September 2010 15:42
Soft Tissue Neoplasm or Hematoma? by Dr. Terry R. Yochum, D.C.; D.A.C.B.R.; Fellow, A.C.C.R. and Dr. Chad J. Maola, D.C. History: This 25 year old female has recently noticed a palpable mass in the upper inner thigh. She doesn’t recall any fall but does ride her horse on a regular basis. Diagnosis: Post-traumatic myositis ossificans. Note the calcific mass near the lesser trochanter which was caused by chronic trauma to the adductor muscles while horseback riding. (Prussian’s disease) General considerations: Traumatic myositis ossificans (myositis ossificans posttraumatica, ossifying hematoma, traumatic ossifying myositis, or heterotopic posttraumatic bone formation) is a condition characterized by heterotopic bone formation in the soft tissues following trauma. The process occurs most often in muscle but may also occur in fascia, tendons, joint capsules, and ligaments. Most occur following any local injury sufficient to cause bruising of the muscle or a frank hemorrhage within it. The most common sites are the brachialis anterior (elbow), quadriceps femoris (thigh), adductor muscles of the thigh, medial collateral ligament of the knee (Pellegrini-Stieda disease), and in cases of rupture of the coracoclavicular ligament of the shoulder.¹The constant pressure of the saddle against the adductors in riders may cause ossification in the adductor magnus and is known as Prussian’s disease, or erroneously, as a saddle tumor.¹Bedridden and wheelchair-confined patients frequently produce heterotopic bone at areas of gravitational stress, most commonly found at the ischial tuberosities. Up to 50 percent of paraplegic and quadraplegics exhibit paravertebral ossification.^1,2 Radiologic Features: The ossifying hematoma may be visible radiographically within three to four weeks after the initial injury.¹ Magnetic resonance imaging may show the intramuscular hematoma from an early stage. Initially, the roentgen appearance is a fine, lacy radiopacity, which is followed later by a cloudy ossification within a well-defined mass. Its size depends upon the degree of initial trauma and the overall size of the hematoma. Eventually, sequential studies demonstrate a bony mass that is very radiopaque in its peripheral margins, with the center of the lesion appearing relatively radiolucent. The bony mass usually measures 4 to 5 cm but may be as large as 25 cm on occasion. The soft tissue osseous mass distinctively has no direct connection with the closest bone. Radiologic diagnosis is essential, since biopsy of this mass in its early stages may show what would appear to be a sarcomatous change centrally. A radiologic sign important in making the distinction between this and a bone neoplasm is the characteristic lucent zone (cleavage plane) between the calcified mass and the subadjacent cortex.^1,2 The mass is usually located adjacent to the diaphysis of a tubular bone, but the cortex of the bone is intact. Other important confirmatory properties are a dense periphery with a more lucent center and decrease in volume with time. Increased uptake of bone-seeking radionuclide may be noted which diminishes with maturity and inactivity of the lesion.¹ Differential Diagnosis: Extraskeletal sarcoma may be difficult to differentiate from myositis ossificans. This condition is rare and tends to occur in older adults. Synovioma, in one third of cases, may calcify and can be located remote from the joint due to its association with tendon sheaths; therefore, this tumor must be given consideration when evaluating a calcified soft tissue mass. A parosteal sarcoma may have a similar appearance, but no lucent zone between it and the diaphysis should be visible. Other soft tissue calcifications such as tumoral calcinosis may present as a densely calcified mass but have an amorphous calcific rather than maturely ossific nature.² Dr. Terry R. Yochum is a second generation chiropractor and a Cum Laude Graduate of National College of Chiropractic, where he subsequently completed his radiology residency. He is currently Director of the Rocky Mountain Chiropractic Radiological Center in Denver, Colorado, and Adjunct Professor of Radiology at the Southern California University of Health Sciences, as well as an instructor of skeletal radiology at the University of Colorado School of Medicine, Denver, CO. Dr. Yochum can be reached at 1-303-940-9400 or by e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it . Dr. Chad J. Maola is a 1990 Magna Cum Laude Graduate of National College of Chiropractic. Dr. Maola is a Chiropractic Orthopedist and is available for post-graduate seminars. He may be reached at 1-303-690-8503 or e-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it Reference 1. Yochum TR, Rowe LJ: Essentials of Skeletal Radiology, 3rd ed., Williams & Wilkins, Baltimore, Maryland, 2005. 2. Goldman AB: Myositis Ossificans, A Benign Lesion with a Malignant Differential Diagnosis: AJR 126:32, 1976. Add new comment