Radiology


Partial Agenesis Of The C-1 Posterior Arch
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.   
Sunday, 14 November 2004 22:15

Embryology—Ossification of the first cervical vertebra begins about the seventh fetal week at the lateral masses and proceeds perichondrally in a dorsal direction, creating the posterior arch of the atlas.  In the second year of life, a secondary growth center for the posterior tubercle develops between these neural arches.  Complete fusion of the posterior arch should be noted between the third and fifth years.1

 

Note the congenitally malformed posterior tubercle of C-1 with posterior arch missing. Osteolytic metastatic carcinoma would not leave such a clear posterior tubercle and is very rare to affect the atlas.
Figure 1 - Note the congenitally malformed posterior tubercle of C-1 with posterior arch missing. Osteolytic metastatic carcinoma would not leave such a clear posterior tubercle and is very rare to affect the atlas.

(Case courtesy of Kelly Jarvis, DC, DABCO; Heber City, Utah)

Description—The basic defect in agenesis of the posterior arch of the atlas is the lack of a cartilage template on which the ossification process builds.  Complete or partial agenesis of the posterior arch is rare, and posterior arch defects, by themselves, should not be the cause of neurologic or biomechanical findings, unless found in association with other anomalies such as Klippel-Feil syndrome.

Radiologic Features—An absent posterior arch can be easily visualized on standard lateral cervical radiographs by the lack of a bony posterior neural arch.  A commonly associated finding is enlargement of the superior aspect of the second cervical spinous process, which has been referred to as a mega-spinous process, representing fusion of a rudimentary posterior arch and posterior tubercle of the atlas (not present in this case).2  One may also observe increased size of the anterior arch of C1, which is thought to be stress related and present in this case.  This is a helpful radiographic sign and suggests a long-standing congenital origin to the defect.

Medicolegal Implications of Agenesis of the C1 Posterior Arch
The integrity of the transverse ligament may also be compromised in the maldevelopment process; therefore, a cervical flexion radiograph should be performed to evaluate the atlantodental interspace.

References:
1. Gehweiler JA, Daffner RH, Roberts L:  Malformations of the atlas simulating the Jefferson fracture.  AJR 140: 1083, 1983.
2. Yochum TR, Rowe LJ:  Essentials of Skeletal Radiology, 3rd Edition, Lippincott Williams & Wilkins, 2004.

Dr. Terry R. Yochum is a second-generation chiropractor and a cum laude graduate of the National College of Chiropractic, where he subsequently completed his radiology specialty.  He is currently Director of the Rocky Mountain Chiropractic Radiological Center, in Denver, CO, an Adjunct Professor of Radiology at the Los Angeles College of Chiropractic, as well as an instructor of Skeletal Radiology at the University of Colorado School of Medicine, Denver, CO.  Dr. Yochum is, also, a consultant to Health Care Manufacturing Company that offers a Stored Energy system.  For more information, Dr. Yochum can be reached  at: 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 Maola is a 1999 Magna Cum Laude graduate of  National College of Chiropractic.

 
Sacral Fractures
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.   
Tuesday, 14 September 2004 21:37

History

This patient fell off a horse while competing in a high level equestrian event. The patient fell directly over the sacrum and experienced immediate severe localized pain in the sacral area.

Discussion

Sacral fractures usually occur as the result of a fall upon the buttocks or following a direct traumatic blow. There are two types: Horizontal and Vertical.

Horizontal (transverse) Fractures

These are the most common type sacral fractures. The most common location is at the level of the third and fourth sacral tubercle, which is near the lower end of the sacroiliac joint. The lateral radiograph is usually required to demonstrate the fracture. Often, the lower segment of the sacrum may be displaced or angled forward.

A horizontal fracture of the upper sacrum, affecting the first or second sacral segments, may occur as a result of falls from a height. It is usually associated with suicidal attempts by jumping ("suicidal jumpers" fracture).

Vertical Fractures

These usually occur as a result of indirect trauma to the pelvis. They are visible on the frontal radiograph, but not the lateral view. The cephalic tilt-up view may be necessary to demonstrate the vertical fracture line, which usually runs nearly the entire length of the sacrum. Normally symmetrical transverse sacral foraminal lines should be carefully scrutinized for detection of the fracture line.

Isolated fractures of the sacrum are uncommon and a diligent search of the frontal radiograph for associated fracture of the pelvic rim or symphysis pubis is often beneficial.

Dr. Terry R. Yochum is a second-generation chiropractor and a cum laude graduate of the National College of Chiropractic, where he subsequently completed his radiology specialty. He is currently Director of the Rocky Mountain Chiropractic Radiological Center, in Denver, CO, an Adjunct Professor of Radiology at the Los Angeles College of Chiropractic, as well as and instructor of Skeletal Radiology at the University of Colorado School of Medicine, Denver, Co. Dr. Yochum is, also, a consultant to Health Care Manufacturing Company that offers a Stored Energy system. For more information, Dr. Yochum can be reached at: 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 Maola is a 1999 Magna Cum Laude graduate of National College of Chiropractic.

References:

1. Yochum TR, Rowe LJ. Essentials of Skeletal Radiology, ed 3. Baltimore, Williams & Wilkins, 2004.
2. Rogers LF. Radiology of Skeletal Trauma, Volume 1 & 2, New York, Churchill Livingston, 1982.

 
Lumbar Spine Compression Fractures
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.   
Thursday, 08 July 2004 21:00

The radiographic signs of vertebral compression fracture are often subtle.  Radiographs of optimal quality are necessary in order to adequately demonstrate these fractures.  Lateral radiographs best demonstrate the fracture features.  Radiographic signs of vertebral compression fracture include a step defect, wedge deformity, a linear zone of condensation, displaced endplate, paraspinal edema and abdominal ileus. 

Compression fracture of L2 and L4 superior vertebral endplates.  Observe the Step Defect—Note, in the presented image, a compression fracture of the L2 and L4 superior vertebral endplates.  There is an anterior step defect at the anterior superior corner of the L2 and L4 vertebral bodies.  Since the anterior aspect of the vertebral body is under the greatest stress, the first bony injury to occur is a buckling of the anterior cortex, usually near the superior vertebral endplate.  This sign is best seen on the lateral view as a short step off of the anterior superior vertebral body margin along the smooth concave edge of the vertebral body.  In several compression fractures, the step defect may be the only radiographic sign of fracture.  Anatomically, the actual step off deformity represents the anteriorly displaced corner of the superior vertebral cortex.  As the superior endplate is compressed in flexion, a sliding forward of the vertebral endplate occurs creating this radiographic sign.   This sign is often gone once the compression fracture heals.

In most compression fractures, an anterior depression of the vertebral body occurs creating a triangular wedge shape.  Occasionally, a band of radiopacity may be seen just below the vertebral endplate wedged shaped fracture.  This has been referred to as the linear wide band of condensation, or the zone of impaction.  The radiopaque band represents the early site of bone impaction following a forceful flexion injury where the bones are driven together.

A sharp disruption in the fractured vertebral endplate may be seen with spinal compression fractures.

Differentiation between old and recent compression fractures is often difficult.  This may be definitively detected by the presence of bone marrow edema on magnetic resonance imaging scans (MRI).  Bone scans maybe be helpful showing increased uptake with recent fractures undergoing the active repair; however, these fractures may remain active eighteen to twenty-four months following injury, which diminishes its usefulness. TAC

Reference: Yochum TR, Rowe LJ:  Essentials of Skeletal Radiology, 2nd ed., Williams & Wilkins, Baltimore, Maryland, 1996.

Dr. Terry R. Yochum is a second-generation chiropractor and a cum laude graduate of the National College of Chiropractic, where he subsequently completed his radiology specialty.  He is currently Director of the Rocky Mountain Chiropractic Radiological Center, in Denver, CO, an Adjunct Professor of Radiology at the Los Angeles College of Chiropractic, as well as an instructor of Skeletal Radiology at the University of Colorado School of Medicine, Denver, CO.  Dr. Yochum is, also, a consultant to Health Care Manufacturing Company that offers a Stored Energy system.  For more information, Dr. Yochum can be reached  at: 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 Maola is a 1999 Magna Cum Laude graduate of  National College of Chiropractic.

 
Lung Pathology or Pseudo-Lesion
Radiology
Written by Dr. Terry Yochum D.C.; D.A.C.B.R.; Fellow, A.C.C.R.   
Saturday, 03 April 2004 16:10

In the pre-antibiotic era, the only treatment for pulmo-nary tuberculosis was rest and or lung resection of the diseased segment.  Secondary or re-infection tuberculosis most commonly occurs in the lung apices.  This patient had surgery with resection of her right upper lung due to pulmonary tuberculosis.  To fill space left empty by the resected lung tissue and to avoid huge mediastinal shifting of the trachea, opposite lung and heart, this open space was filled with a foreign substance.  The substance was “lucite balls” and was packed in the open space.  Its appearance on standard radiographs was quite striking, leaving the impression of “ping pong” balls in the lung.  This “plombage” procedure is no longer used today with the advent of antibiotic therapy for pulmonary tuberculosis; however this may still be encountered on radiographs of the geriatric patient population.

Dr. Terry R. Yochum is a second-generation chiropractor and a cum laude graduate of the National College of Chiropractic, where he subsequently completed his radiology specialty. He is currently Director of the Rocky Mountain Chiropractic Radiological Center, in Denver, CO, an Adjunct Professor of Radiology at the Los Angeles College of Chiropractic, as well as an instructor of Skeletal Radiology at the University of Colorado School of Medicine, Denver, CO.  Dr. Yochum is, also, a consultant to Health Care Manufacturing Company that offers a Stored Energy system.  For more information, Dr. Yochum can be reached  at: 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 Maola is a 1999  Magna Cum Laude graduate of  National College of Chiropractic.

 
Dish Syndrome
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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.   
Saturday, 28 February 2004 00:00

Considerations

Diffuse idiopathic skeletal hyperostosis (DISH) is a generalized spinal and extraspinal articular disorder that is characterized by ligamentous calcification and ossification.  The most prominent radiographic expressions of this disease are encountered in the spine involving predominantly the anterior longitudinal ligament.  It is a distinctive disease and does not represent ankylosing spondylitis or degenerative joint disease.  An incidence of 12% of middle-aged individuals in the United States has been estimated.1  Observe the thick flowing hyperostosis projecting from the anterior vertebral bodies of L1 through L4. This is characteristic of DISH.

Clinical Features

Complaints by the patient are similar to those of degenerative joint disease, involving the fifth or sixth decade of life, with morning stiffness and low-grade musculoskeletal pain, especially of the spine and its related articulations.  An additional complaint is approximately 20% of DISH patients have dysphagia due to anterior proliferative bone growths from the cervical spine. 

Radiographic Features

The definitive criteria for the diagnosis of DISH are as follows:2

  1. The presence of flowing calcification or ossification along the anterolateral aspect of at least four contiguous vertebral bodies.
  2. The relative preservation of intervertebral disc height of the involved segments and lack of other associated signs of disc degeneration.
  3. Absence of apophyseal and von Luschka joint ankylosis.

Target Sites of Involvement

Statistically, the most common spinal region affected is the thoracic spine, particularly from T7 through T11.  The flowing thick hyperostosis is a classic radiological appearance.  The cervical spine is the second most common site with exuberant anterior vertebral body hyperostosis occurring from C4 through C7.  Lumbar involvement is the third most common site and most prominently in the upper three segments.  Initially, the hyperostosis begins from the middle and anterosuperior vertebral body margin, extending upward and tapering at its distal extent, simulating a candle flame.3  

Differential Diagnosis

The most difficult differential exclusion includes ankylosing spondylitis.  The syndesmophytes of ankylosing spondylitis are fine and delicate in their appearance while in DISH the spondylophytes are very large, thick and irregular.  The lack of extensive sacroiliac joint disease is also a helpful differential point since only rarely in DISH will the SI joints show ankylosis and when this occurs it is in the upper one-third of these joints (fibrous portion) rather than the lower two-thirds (synovial portion), which is classically affected by ankylosing spondylitis. TAC

Dr. Terry R. Yochum is a second-generation chiropractor and a cum laude graduate of the National College of Chiropractic, where he subsequently completed his radiology specialty.  He is currently Director of the Rocky Mountain Chiropractic Radiological Center, in Denver, CO, an Adjunct Professor of Radiology at the Los Angeles College of Chiropractic, as well as an instructor of Skeletal Radiology at the University of Colorado School of Medicine, Denver, CO.  Dr. Yochum is, also, a consultant to Health Care Manufacturing Company that offers a Stored Energy system.  For more information, Dr. Yochum can be reached  at: 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 Maola is a 1999  Magna Cum Laude graduate of  National College of Chiropractic.


References

  1. Yochum TR, Rowe LJ:  Essentials of Skeletal Radiology, ed 2.Baltimore, Williams & Wilkins, 1996.
  2. Resnick D, et al:  Comparison of radiographic abnormalities of the sacroiliac joint and degenerative joint disease and ankylosing spondylitis. AJR 128:189, 1977.
  3. Dilhmann W:  Current radiodiagnostic concept of ankylosing spondylitis.  Skeletal Radiol 4:179, 1979.
 
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