Congenital anomalies and normal variants

*thesis – attachment sites of ligaments and tendons via Sharpey fibers

*area of evaluated bone

1. 
   change position and the “hole” disappears
   
2. 
   hole inhanced when superimposed ant/post onto each other
   

TROPISM

*CT/MRI more accurately identify

*AKA – asymmetric facets

*is there clinical significance to spend $ on better imaging?

*IVF @ C1 in flexion lateral?

*solid white rim

*most superior form of blocked vertebra

*no separation of occiput and C1

*usually unified @ occipital-atlanto joint

*increase in ADI instability (don’t adjust C1-C2) b/c potential for cord damage

*tends to have contents within it

*premature DJD

*TOMOGRAM (blurogram)

~blurred ; between plain film and CT

~occipitalization demonstrated by outer shelf of occiput continual w/ lateral

mass and posterior arch of C1
ATLANTOAXIAL SYNOSTOSIS

*C1-C2 blocked vertebrta

*check Spinolaminar Line

~no line w/ large anterior tubercle = front/back somite didn’t separate

~well seen in open mouth view

!no acial load is considered safe b/c the bone is a C shape

*the more the anterior tubercle is like the odontoid in size =

1. 
   stress response
   
2. 
   hypertrophy of anterior tubercle
   

SPINA BIFIDA OCCULTA

*agenesis of posterior tubercle of C1
V SHAPED ADI COMMON IN CHILDREN

NO POSTERIOR ARCH OF C1

*tends to be megaspinous of C2

*growth center never separated up and down?

1. 
   somite stayed
   
2. 
   stress hypertrophy
   

OSSIFICATION OF LIGAMENT (soft tissue calcification)

*aka’s

1. 
   arcuate foramen
   
2. 
   posticus ponticus
   
3. 
   kimmerly anomally
   

*common in 15% of population (normal variant)

~clinically significant for 10% of those

positional headache

vertebral artery dissection

signs consistant with VBAI

*ligaments consistency of toothpaste

*Gatterman

*adjusting doesn’t change

~ask questions to relate position

~VATT = artery test

*lateral mass to Spinolaminar Line

SOFT TISSUE CALCIFICATION

	PHYSIOLOGIC	DYSTROPHIC	METASTATIC
SERUM CALCIUM	Normal	Normal	Increase
TISSUE	Normal	Abnormal / damaged	Overwhelms normal tissue
EXAMPLES	Thyroid Rib Arcuate foramen	Calcific tendonitis Calcific bursitis Myositis ossificans Gout	Hyperparathyroidism

C1 TOO FAR FORWARD

*Spinolaminar line doesn’t go all the way up

*does have arcuate foramen

*ADI too big!!!

~anterior tubercle slips forward due to abnormal transverse ligament

~if ADI fine think

1. 
   odontoid fracture
   
2. 
   os odontoidia (congenital)
   

*patient has no idea

*lock out doesn’t lock out the same

*don’t do anything special

*single spinolaminar lines

*rudimentary disc where disc should be

*how does this happen?

1. 
   congenital – failure of somite segmentation from North to South
   
2. 
   discectomy – 2 bloody endplates heal together
   
   1. 
      in surgery it will be anterior or posterior fusion
      
   2. 
      when both fused = congenital
      
3. 
   infection may destroy disc and end plates will heal together
   
4. 
   inflammatory arthritis
   
   1. 
      fibrous ankylosis
      
   2. 
      boney ankylosis
      

~don’t adjust ~hypermobility above and below joint

~DJD mc complaint ~ADI instability in flx/ext views

*WASP WAIST appearance – only in congenital blocks

*anomalous IVF
*rudimentary disc – shadow of a disc, but not full

*fibular strut – vertical cortical line in middle of vertebra

~disc tear

~anterior longitudinal ligament

*MRI will help check spinal cord canal and determine cord physiology

*COC1

*most superior block possible

*black spot @ middle = decrease density = rudimentary disc

*congenital – anterior/posterior fusion (sp fused too!)

*symptoms

~suboccipital muscle spasms

~VBAI; nystagmus, nausea, vomiting, dizzy, ataxia

SPINA BIFIDA OCCULTA @ C2 (spina bifida unimportanta!)

*nothing is wrong w/ the body

*no change in patient activity

*L5 w/ SBO

~statistically increases association with herniated discs

~incomplete development of annular fibers

~better the patients preventative health = back school

*clinically silent

*will see a sclerotic / cortical line as opposed to ragged

*trabecular fracture look

*multiple blocked vertebrae

*congenital fusion

*Sprangle deformity – unilateral elevation of scapula

~failure of scapula to descend

~not placed in proper place in relation to thorax

*os odontoidia – no odontoid

~not required but often seen in klippel-feil

~anterior tubercle of C1 pressing anteriorly on pharynx

~transverse ligament or odontoid has failed

*CT study of skull (bone window) – bone is white

*soft tissue looks same on inside and outside

*inner/outer table

~band of bone

~diploic space – marrow, vascular supply

*frontal bone = frontalis

*intrudes inward = internus

*black circle @ back of skull, bilaterally

*probably congenital

*some risks, but not much

*could be unilateral, but most often is both sides
MEGA SPINOUS OF C2

*can’t say agenesis of C1 b/x

1. skull not sitting on C2

2. some bone seen @ anterior

*follow white lines – no interrupted cortex and maintains parallel

*substantial longus colli muscles

HYPOPLASTIC POSTERIOR ARCH OF C1

*check thru everything

*Run lines

~spinolaminar line not good = missing C1 posterior

1. transverse ligament = check ADI, if normal…move on to

2. odontoid not attached – draw axis line (0-8 degrees)

(if normal…move on to)

3. 
   must be congenital!!
   

UNUNITED GROWTH CENTER OF T1 TP ON RIGHT = cortical margins present

*the TP’s of C7 don’t go up and out like T1

*can be fully participating or not at all

*has joint capsule, synovial fluid, proprioceptors

*hypertrophy of right TP

*with cervical rib on left side
SPONDYLOSCHISIS

*spina bifida oculta, but no quite

*no anterior or posterior tubercle of C1

*creates 2 C shaped bones

*midline defect
DOWN’S SYNDROME – trisomy 21

*mc autosomal problem (1/600)

*signs and symptoms

~brachycephaly ~slanting eyes

~samll nose w/ flat bridge ~protruding tongue

~sepressed cerebration

*everyone must have radiographs and letter from physician to participate in sports

*SPINOLAMINAR LINE

~very large ADI – spinal canal very small

~sensory testing important

*doing film study – take one, then check it before moving on

~if you find a fracture, stop filming

*MRI must be done when cord is being compromised

~document the cord status

~will need stabilization surgery

*20% have abnormal transverse ligament

~stress views

~pre-participation

UNSTABLE OS ODONTOIDIA

*posterior tubercle too far forward

*ADI very intact

*odontoid

~sclerotic base – cortical (not a fracture)

~very close to anterior tubercle

*considered uncommon

*ununited ossification center or ong standing non-union fracture from childhood

*worry about cord!!

*symptoms

~suboccipital muscle spasm and headache

~alterations of sensory coinsiding w/ canal stenosis

~vertibro-basilar artery insufficiency = VBAI
DYSPASTIC POSTERIOR ELEMENTS

*dens forward

*anterior tubercle small

*MPR unusual joint movement and openings

*no surgery b/c have normal ROM

*treat them!!

*mis-shapen vertebra = series of hemivertebra