Congenital anomalies and normal variants



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CONGENITAL ANOMALIES AND NORMAL VARIANTS
PSEUDOTUMOR

*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


*cannot be seen on plain film!!!!!

*CT/MRI more accurately identify

*AKA – asymmetric facets

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


CRANIOVERTEBRAL SYNOSTOSIS/OCCIPITOATLANTO FUSION/OCCIPITALIZATION

*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?


BIG ANTERIOR TUBERCLE

  1. somite stayed

  2. stress hypertrophy

OSSIFICATION OF LIGAMENT (soft tissue calcification)

*aka’s


  1. arcuate foramen

  2. posticus ponticus

  3. kimmerly anomally

*increase room b/t occiput and C1

*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)

LARGE PARADENTAL SULCUS

*patient has no idea

*lock out doesn’t lock out the same

*don’t do anything special


STYLOHYOID LIGAMENT CALCIFICATION
BLOCKED C2/C3 VERTEBRA

*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

*clinical significance

~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


OCCIPITALIZATION W/ INCREASE ADI

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

*COC1

*most superior block possible


BLOCKED VERTEBRA

*black spot @ middle = decrease density = rudimentary disc

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

*symptoms

~suboccipital muscle spasms

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


STEEP ATLANTO-AXIAL ANGLE
ANTERIOR TUBERCLE OF C1

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


UNUNITED GROWTH CENTER

*clinically silent

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

*trabecular fracture look


KLIPPEL-FEIL SYNDROME

*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


HYPEROSTOSIS OF SKULL

*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


PARIETAL FORAMEN

*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


DEVELOPMENTAL CLEFT OF ANTERIOR BODY OF C3

*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)



  1. must be congenital!!

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


CERVICAL RIB (DIGIT)

*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


CERVICOTHORACIC TRANSISTIONAL VERTEBRA

*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!!


CERVICO THORACIC SCOLIOSIS

*mis-shapen vertebra = series of hemivertebra



*2 pedicles on one side w/ their own posterior elements

*called scrambled spine

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