the following is a medical media production from
WRAMC-TV
ladies and gentlemen,
this session will deal with the
upper cervical spine in childhood.
It's actually a lot of the stuff will hold
for adulthood and but I will
concentrate primarily on the child.
And uh one of the reasons I got
interested in this area is because it was
difficult for me to understand.
And I think I find that
after residents finished three or four years of
training,
if you could give him a diploma that says
uh qualified and diagnostic run
technology and will never have to read a cervical
spine film for the rest of his life.
He'll pay you double for that diploma
and would be just as happy if they never had to look at another
spine in their life.
Isn't that right?
I know I haven't seen 1/4 year resident yet that
said that I really understand that cervical spine
and that's one of the reasons I got interested
because I was the same way.
I mean I was hoping nobody would ask me anything like
that on the boards.
Uh it's not so difficult.
The real big problem is that there are some normal
variations that you might not be aware of in
Children.
But the real big problems are a bunch of weird
anomalies that will work through slowly this
morning.
Now as I mentioned,
some of this stuff will apply to an adult and I'll
mentioned uh when the areas
that this would pertain to.
First thing our normal findings that cause
problems.
Now this is one of the first things That
one ought to appreciate because I as a
matter of fact,
10 days ago had a telephone call from
one of our former residents from a town
city,
small city in Texas.
And he said,
you know,
we had a kid with a cervical
C12 dens distance of
four and I didn't know what to do about it.
You know,
the kid had stiff neck,
he was in an accident.
And The first thing you have to
appreciate is this in an adult,
the usual figure is if it's 2
mm the space between anterior
arch of C.
One and the dens,
you're probably okay.
That doesn't mean you can't have a fracture.
It just means it's not dislocated,
it's not moved around.
If it's 2.5,
people will worry if it's three,
everybody will agree that that ought to be abnormal.
In 99% of cases that's in an adult.
In a child,
it's quite different.
Obviously in infancy,
it's going to be bigger because everything's under ossified.
But in Children that are 78,
10 years old.
Very often this space is three
millimeters and normal.
I mean very often,
I mean I can find you half a dozen of these a week
in our institution Very often it will be three.
Occasionally it can be four and occasionally it can be
five and still be normal and this one is normal
and this one will be about four.
So you have to be careful you have to be careful.
That's not to say that true.
Dislocation like in this patient with
rheumatoid arthritis of the spine and laxity
of the joints between C.
One and C.
Two.
You notice the space is much more than five there and
on flexion here it opens up considerably.
That's not to say that this doesn't occur and that's
distinctly abnormal.
But the thing is it can be
Normal up to five.
That's not gonna happen every day.
But four is more common and three is
really garden variety space.
I can guarantee you that if you see a lot of
pediatric films.
So that's number one.
Now here's another thing this
will hardly ever come up
unless you get an oblique spine.
Or better still unless you have skull
films for head trauma
and you get a kind of an oblique cervical spine to go
along with it.
This is the sin condo sits sits anterior.
It's the sin condos is between the arches and
the body and dens of C.
Two.
You will see it only only on the
oblique film and there it is there you can see the dents in the
body and then there's the sink on grosses between The
dense and body of c.
two.
But it's this thing right here,
this oblique line that shows up on oblique
views.
Now this is what will happen.
I don't know how the neurosurgeons are around your parts,
but at our place,
almost every place I've been,
they don't come and see anybody unless he's got a
skull and spine films.
You know,
whether he needs them or not.
I'll tell you that right now he's got him.
Part of it is because they're busy.
Part of it is they don't want to miss anything for medical legal
purposes.
So you're gonna end up with skull and spine
films and the kids probably going to be okay in the head
and somebody's gonna notice this.
And if you don't know that that's a normal simcon dross is
seen only on a bleak view.
You'll get sidetracked by that and you may end up actually
polito ming and everything else.
This is normal Silicon Drusus of C
two.
Now,
very fortunately,
I had a case like this,
this is simcon Drusus and fracture and it makes a very good
point.
You see here we've got two arrows.
Is that in focus there?
Is that in focus for everybody.
Okay?
Now you've got a shouldn't give the
secret away,
but this is about 15 ft and I can't see too
well just well enough at 15 ft
to get my texas driver's license.
That's all.
But there are two cracks here up,
interior is the simcon grosses and post
your ear is the fracture through the arch,
most of the times you're gonna get a fracture to the arch,
it'll be poster to the sin Condra Asus,
you know and you're not going to happen to come up with a film like this too often
but there's the fracture and there's the sink and roses.
But this is the point I want to make.
If you see something on lateral view,
do you see there's a crack here in the arch of
C.
Two.
It's a fracture because you never see the normal
simcon Drusus on lateral view because it's an
anterior structure and you have two oblique the
spine.
So the important thing to remember there is if you see it
on oblique and you don't see it on the lateral it ought to be
the same condo sis you never see that sink.
Andreas is on a good lateral film to
normal findings so far the normal distances C.
One to the dens and this Sin Condra Asus.
Now posterior
arch of C.
One defects.
Congenital defect versus fracture.
How do you deal with this?
Well,
I have some of these diagrams which I've redrawn
myself and modified after uh the
diagrams as they appeared in the book by von
torque lists and jelly.
I think that's where you pronounce it is a good little book from
europe and you can have a whole
host of these arch defects very prone to
it.
How do you tell them apart from a fracture.
Well first of all they look
weird.
That's a good way to approach it.
They look strange.
Here's a car accident or a motorcycle or
something.
I don't know what it was.
It was a trauma case number one.
There's nothing wrong here,
right,
because you can't have a normal curve to the cervical spine
and have a whole lot wrong.
You can't even have muscle spasm.
Besides this girl could tell you if anything was wrong with her
next,
she'd say,
uh huh.
So you could have saved her all the trouble here.
But we got some X rays and found this thing.
And of course,
if you don't realize that that's a big poster arch
defect that's congenital,
you'll get worried about it.
First point then,
weird.
Second point,
the bigger the defect,
the more likely it's going to be a congenital
defect.
And the poster fragment is often bizarre
appearing and very often triangular
and tapering as you go up front here are two
examples of poster arch defects,
with the posterior fragment being
triangular.
Okay,
now,
if you're gonna have a fracture back there,
it'll be an extension injury and it may be
associated with other
fractures of C.
One usually is,
but fractures if you will just remove this
anterior line which is an artifact,
there's a bilateral fracture here.
Through the arch of C.
One right here and right there fractures
are narrow defects.
They're straight,
they may be unilateral or bilateral.
There are there is no indication of any other
anomaly.
There's no peculiar looking C.
one.
There's no big gap.
They're small,
linear.
Sometimes they're a little crooked like this over here,
that's an extension injury with a fracture through
the arch of C.
One on frontal view.
This patient also had a displaced lateral
mass of C.
One.
This is an injury,
they're fine,
they're hardly ever Two or more than two
in width.
The gap just doesn't separate that much.
So you're looking for a narrow,
crooked or straight to defect as opposed
to a big gap there with a triangular posture
element.
Now I'll show you how this becomes useful.
This was a fortuitous case.
And the next thing and these bright lights in
front of me,
if you really don't need them,
you might dim them down because they're having trouble seeing
these X rays.
I can tell with these bright lights and so am I.
Now,
here's a patient is an adult with a
car accident and a sore
neck isn't that much better.
Radiologists hate bright lights,
don't they?
I mean we were morning and evening
people then we hide with our illuminator
and so forth.
And if the sun went out
probably wouldn't bother us too much,
you know?
Um Thank
you,
that's much better.
Now,
here's a patient with a straight neck,
okay?
There's something wrong here,
but you figure out what it is.
And I was walking by the view box as well.
The neurosurgeons were looking at this and
this is a really interesting case because
the neurosurgeon said,
you know,
I don't know there's pain but this,
you know,
just she didn't have that much trouble.
This is a combination,
a very good case to make our points here.
# one,
it does look triangular,
doesn't it?
It looks anomalous.
What do we have here?
Look closely at this next view,
which is just slightly oblique.
You have a fracture through a thin
arch on one side,
that's what's given her pain.
And on the other side you have a congenital defect with
a triangular components.
So,
you have here a hypoplastic
C1 thin on one side,
gap on the other side,
the thin side fractured that's giving her pain,
nothing else fractured.
What does this mean?
This means pain and spasm,
but a stable spine.
This requires minimal treatment.
You know,
you're not thinking of an unstable dislocating spine.
We know why she's got pain,
but we're not as worried as if we had a whole lot of
fractures up there and instability.
And I would tell you from the onset that your job in
the cervical spine is not so much to do
detect every little Snookie fracture in there,
but to decide whether you got stable or
unstable spine,
that's the most important thing.
So,
don't forget,
after you're finished looking at all the cracks and weird looking
things and so forth.
You have to say to yourself,
is it stable or unstable because that's the only thing,
the neurosurgeon or the Ortho pod,
whoever usually looks after these things is
interested in.
This is a fracture,
but it's perfectly stable.
Nothing else with it had cuts in the frontal plane
and nothing else associated with it.
When you understand this,
you can figure it out.
And then the neurosurgery resident said,
no,
that makes sense.
He was a senior,
was a good man,
he's a senior resident there were he was finishing up and
and he said,
now that makes sense.
He said,
I couldn't figure out,
you know,
the degree of clinical finding just didn't fit
what we were seeing.
This is just to round it out and to emphasize to
you that C one comes off pretty
funny looking a lot of times it is very prone to
anomaly,
hypoplastic and un united in the
back.
Very common.
Nothing else wrong here?
Very thin unilateral arch.
It almost looks like some kind of aneurysm will bone cyst or
something like that.
That's just a thin unilateral arch.
Incidental finding just found that I was going through a bunch of
cervical spine films and three days ago,
just before I came to Washington.
This peculiar thing with an overgrown
occipital condo here,
see one fused to see to a most
peculiar anomaly in a newborn.
And I don't think this will lead to any difficulty.
But it's just to emphasize that this area is
really prone to anomalous formation and that's
what's going to be our big problems.
So we've covered some normal findings in the C.
One area we've touched on anomaly and we would
emphasize that this area is very prone to
anomalies.
Before I go onto anomalies of the dens.
I would like to cover this which is kind of a pet
topic of mine last year we had an
exhibit on this at the at
both the meetings Rank and Ray and R.
S.
N.
A.
And and I have a paper on this that should be coming up pretty soon
in radiology.
And the reason I mentioned that if you remember anything
about this whole business about whether it's dislocated
or not,
Don't do anything until you make the
observation that c.
two is anterior early
displaced on C.
Three.
Now don't forget that if it isn't don't bother with
a line or anything else,
I'm gonna tell you.
It's designed to bail you out only
when C.
Two is anterior early offset displaced
or dislocated on C.
Three.
Now that's I've found that since I presented this,
people want to apply this line for everything.
Don't do it unless C.
Two is offset on C.
Three.
Now it's designed basically to tell you whether you've got
true versus physiologic dislocation.
Take this 14 year old motorcycle accident in the
emergency room.
See all this junk back here.
He's laying down on the table.
This is the film was taken cross table lateral.
Now C.
Two is offset on C.
Three.
Right?
The question is should you move them and of
course this is the one time when the neurosurgeon
Ortho pod,
whoever else would like your opinion.
Not because he thinks it's so valuable
because he wants to share the lawsuit with
you don't get yourself.
Not very often does he think your opinion is so valuable?
I found that that it really doesn't make a deal read
what they want out of the thing and I don't make any bones about it and
what I say about him they deserve because
whatever the you know,
whatever the band plays they sing Stardust
and that's true.
Uh And uh I'm not gonna
convince them but for our benefit,
let me say you this that when you see this they're gonna
ask you.
So if you don't wanna up your premium you
have to try to figure out whether they should move,
you know,
you can't tell them.
Well how about move them just a little bit
you know and uh they won't buy that
stuff.
So that's how I got interested in this.
Well before we figure out how to bail us out out
of this situation,
let's look at something here in the in the childhood
spine.
This does not occur in adults for the most part this is
Like 16 years and under for the most part
if you extend there is no moral alignment
right?
If you flex very often you get C.
To offset on C.
Three like that sometimes three on four and four on
five and then it peters out.
So it may be step.
Like now we've known this for a long time,
it's been described and everybody is familiar with this.
Where does the motion occur?
It occurs through this joint here.
Now compare it on this side and on this side
with flexion there's a lot of motion occurs through the
C.
Two,
C three above seal joint.
And when this occurs,
C two will slide forward on c.
three and the body will look offset.
That's how it happens.
And that's how you create the thing number one,
if you can get this much motion out of spine,
nothing's wrong.
Right.
I mean it's gonna be hard,
but I want to show you here,
not that you have to flex the spine
to use this line that I'm going to show.
You know,
that's not the thing.
I'm only showing you how this occurs.
This occurs inflection because of motion through C.
23,
A popsicle joint area.
Now the thing that's important is look at the
alignment of the posterior arches of C.
12 and three in extension C
two Is posterior to both one and
3 in the neutral position.
It maintains that configuration
most important,
however,
with flexion,
in other words,
with the mechanism that produces C.
Two and C.
Three offsetting these three things come
into almost a straight line
alignment.
Almost a straight line.
In fact,
most cases it'll be straight line in this one,
it's just about a straight line And that's
very important because I looked at a whole bunch of
these,
I mean it must have been like 500 or more.
It's easy to do.
Every chest film will have you a neck like this.
You know,
you can see it on 50% neck film,
sinus skull,
whatever you want.
There's gonna be a little bit of cervical spine.
So you don't have to have a cervical spine
series to look at this,
just look at anything with cervical spine on it
and you'll find out that it is very difficult
for a normal child to do anything else but a
line that up into almost a
straight line.
Consequently,
If you have C2,
offsetting like in our friend in the motorcycle accident
and you draw a line from the cortex of C
one down to the cortex of C three,
Take this line from here to here and watch what
happens to it at Sea two.
If it goes through C2 Cortex
if it touches it or if it comes
within one millimeter of the cortex of C.
Two,
I believe that the only thing you have is
pseudo dislocation or in other words,
you do not have an unstable spine.
Now,
once in a while I found that in a normal kid it
would be a millimeter distance between the line
and see too.
And that's why I say a millimeter is probably
still okay and I'm not a great measure,
I'll tell you.
But I would recommend to you that you do take the ruler out here
and measure millimeters because it's going to become very
important.
As you'll see in just a few moments,
I'll rephrase this.
You must have C two C three offsetting
in this case.
It's pseudo dislocation or physiologic.
It's physiologic because of the position
of the spine.
And this line confirms that it is physiologic
because the line drawn from the cortex of C one anterior
aspect of it to see three cuts through the
cortex of C.
Two.
As long as it comes within one millimeter anterior
surface,
you're probably okay.
Now let's look at another one.
You don't have to flex the spine.
People have asked me that and don't do it.
Take the first film you get.
And if this is offset like we have here,
this is another trauma case.
If this is offset,
then you have to decide what to do with this.
Now,
here comes one little problem that I want to outline to you.
This is hypoplastic and we know C1 is
hypoplastic.
So where are you going to measure?
Be careful.
This is not the posterior cortex here.
This is the posterior cortex of c.
one.
Now I had a resident that measured it in the wrong place,
it still came out.
Okay,
but you must know where to measure this thing and if you can't
figure it out,
don't put the line on it isn't worth it.
You'll just make a mistake,
you have to see the post your cortex.
However we did find it and there it is right
there.
And if you draw it down here,
this is just physiologic.
Now,
why is that important?
I'll tell you why.
Here's,
here's the reason this kid has a
stiff neck,
it's a car accident And the neurosurgery resident,
this is a different 1.
1 I don't care so much about.
And he said I
wasn't worried about that dislocation until I
saw the soft tissue swelling.
Oh yeah,
he saw it down here and
when he saw this down here and he put it
together with this and the kid had tongs slapped
on for friday night and and he
stayed with him until monday morning until they got laminate grams
of the whole thing.
You see.
Well number one,
this was normal.
If you applied this line,
the resident applied it incorrectly.
So he wasn't sure how are you gonna get swelling down
here and not up there if you have a
dislocation up here.
So his thinking is all screwed up and this kid
got two tongues in his head and spent the whole
weekend over there.
Well actually it was a good reason because the kid
had intra cranial contusions and so forth and
was jumping around all over the place and they figured this was the
best thing,
but you see how mixed up the thinking.
Get everybody with kids wouldn't mind having a couple of
tongs at home,
wouldn't you?
Five o'clock?
You know,
just if we were born with two holes in their PJs,
really at five o'clock in the afternoon,
the mother just slap on the tongs over there,
you know,
and the best way to keep a two year old down,
I'll tell you.
And uh if you have any two year olds,
you know what I mean?
And uh see the thinking was all
screwed up and there was nothing wrong over there.
So one other thing,
watch out for this.
If you're not sure where to measure this,
don't measure it,
you'll just get into trouble.
And the other thing,
you do not have to don't flex the spine,
take the first one,
that you get to make the observation that
C two is offset on C three.
And if this line measures within normal range,
it doesn't make any difference how bad that looks.
You're okay.
There is nothing wrong with this kid,
It looks terrible in this infant.
There is nothing wrong,
this is pseudo dislocation.
And I believe the line is helpful and it's worked for
me and I'm gonna show you why it
works,
because if you have true dislocation,
you're going to have a fracture
through the pericles,
or arches a so called Hangman's fracture,
bilateral unstable spine.
What's happened here,
motion did not occur through the c.
2,
3,
apophis seal joint Motion.
Now instability is located through
the arches,
now see two moves forward to be offset
on C3.
You must make that observation here.
You can obviously see the fracture so it's redundant to apply the
line,
but I want to show you why it works.
See two now moves forward,
so do the base at the base of the pericles,
but it carries C.
One with it.
Do you see that?
So when this now slides forward it carries c.
one,
but see to arch remains
posterior.
It remains in the extended or
neutral position.
And as a matter of fact,
this line will now measure two or more.
And if it measures the distance there measures two
or more,
you should assume that you have an unstable spine.
And you ought to look for a hangman's
fracture.
Here's another case missed in the emergency
room,
missed in the emergency room because many of these
fractures are difficult to see there is a fracture here.
You may not see it.
What's the most important thing.
What caught their eye?
It didn't catch their eye actually,
a very good resident of ours picked this up the next
morning and she looked at this and she said,
that looks a little offset And then she
looked at this and she said,
Gosh,
if you drew that that would look a little bit on the
generous side.
And as a matter of fact,
if you do draw that line,
look at from here to there.
You notice that the gap is two from the
Cortex.
And here is the lamb in a gram
with a definite fracture here.
Now you see the first one had tongs in there.
He didn't need them.
This one didn't have tongs needed them,
missed until the next morning.
And the observation of C23 offsetting
was not made by the people looking at this.
You must make that.
Then you can apply the line and it will be very helpful.
I'll summarize and then I'll give you one case that smack
down the middle and I was very pleased when they picked
this other one up.
This if it's abnormal it will almost always be with a
Hangman's fracture.
But it may be with other things.
But I'm gonna say most of the time if it misses C.
Two by two millimeters or more,
it's abnormal.
You can assume there's an unstable fracture over there.
If it misses it by 1.5 mm,
be suspicious.
And use it only if C2 and
C3 are offset,
don't use it for anything else.
Now here's a case that's right down the middle and also
you don't have to flex the spine or do anything.
Just take the first film you get here's a patient.
These are a little dark.
I'll tell you why they're dark.
They're emergency room films.
You only get very light or very dark films in the
emergency room at least in ours.
I thought first is because it was all done at night.
But I don't think that's the that's the answer.
But they are dark and I want
and you ought to appreciate that because this is
exactly the kind of film you're gonna be working with.
Now here,
is there anything going on here
offset a little here and suspicious
measure this line and this is I have to
take a ruler and measure this because my eye is not good enough to
tell one from 1.5,
2 and over when you measure that,
that's going to be to some people,
one to other people,
it will be 1.5.
And my point is,
if you're not sure,
don't slough it off as normal.
If you have any question that it's 1.5
or beyond the normal limit of one millimeter,
do something else about it.
And the best thing to do is immobilize them
and get yourself some cuts because here's a lamb instagram,
it's offset.
Now it's clearly two millimeters in here.
You can always get a beautiful measurement in laminar graffiti
and there's the fracture on one side and there's the fracture
on the other side and this is another unstable
spine that needs stability,
you see.
And this is right down the middle.
This was 1.5 millimeters and that's exactly
why I put that in a long time ago because I think
that anything over a millimeter,
you ought to be suspicious.
Anything over 2 mm is
abnormal.
You'll you'll get screwed up on one case sooner or later.
But it's not gonna be a big thing if you make the errors on the
correct side.
In other words,
don't slough it off as normal.
If you're not sure,
you don't have to flex the spine and above all,
don't apply the line unless C.
Two and C three are offset.
Well,
that'll be enough of that.
Except for one thing,
When you have spasm,
C2 will be angled on c.
three.
It is not dislocated.
If you measured here,
it still would be normal.
How do you decide whether you have dislocation or
just angular ation?
Well,
you draw a line down the poster aspect of C.
Two and if it misses C.
Three,
it can't be offset right.
It can't be dislocated.
It would have to cut through c.
3 to be anti really displaced.
So if it's just angled,
don't apply the line.
And I mention this because this is very common in Children.
They stand like this with the neck kind of straight for
you or it's actually has spasm or somebody's got
their hand on top of the head to keep them still
and they're fighting it and they will have a spine like
this all screwed up,
look at the soft issues,
this is all normal,
but this is not offset.
If you measure this line back there though,
you'll be misled because it does miss it by 2
mm because this spine is basically in the
neutral position.
And if you take the line
along the poster aspect of C.
Two and draw down,
extend it down along C.
Three,
you'll notice that it mrs C.
Three and if it misses C.
Three,
it is not offset.
I mentioned that because that is the major pitfall in
applying this line in Children.
If you have angular ation without offsetting and
you determine whether it's offset by aligning the
poster aspect of C.
Two with C.
Three.
If it's not offset,
don't apply the line because it will lead you astray.
You must have offsetting.
This is angular ation only very
common.
You can do it.
Just tell them to hold their neck nice and stiff like this
angular ation only.
Okay,
I'll just let you think about that for a minute because that's tricky.
You have to take the Poster aspect of the
body of c.
two and a dense and extend the line down here and once again,
if you're not sure,
proceed with another with lambda
grams or whatever else you want to exclude a fracture
only when you are sure that there is no
offsetting.
Should you say it's okay if there's any
uncertainty in your mind,
proceed with your work up.
But you'll save yourself a lot of trouble if you appreciate that
angular ation occurs like this without offsetting because
this is very common.
Well,
I spent some time with that because if it's not used
properly,
it will lead you astray if that line is used
properly,
it is very helpful.
And I think I've illustrated with two cases how helpful it
can be.
It could have saved tongs for one kid and two other
ones that could have gotten him immobilized a little earlier.
Now Ryan nik it's not too
much exciting for us for Rinek.
I mean,
it has a classic history and so forth.
The only thing that's important about Rinek is that
if you can determine what's midline,
are you gonna take the the thoracic spine is
processes are you going to take the cervical ones?
I finally decided I'd rather take the thoracic ones
because that's the only part of the spine that's straight.
But others will measure the spine ist processes of
the cervical vertebra.
Well,
you figure out where midline is and you can
decide for yourself which one you want to use.
I use this one right here and then you decide two
things If the mandible is rotated this
way and the spine ist tip of C.
Two is on the same side of the line as the
mandible rotation,
then you have what's called subluxation with the rye
neck and they're still just gonna treat it conservatively.
If this C.
Two spineless processes on the opposite side to
which the neck,
the mandible is turned then you just have a
positioning abnormality.
The kid is just turned like this.
But you have with wry neck a so called
subluxation at this level C.
One C.
Two.
And if when you have that The spine
ist tip of C.
two will end up on the same side of that midline
as your mandible.
Okay.
And that's all I want to say about Rinek.
Now now we're going to get into anomalies of the
dense and it may be just
as important here to sort of get an overall view
as to look at each thing in detail.
So I'm gonna go through a whole bunch of stuff here to
give you an idea.
Now don't don't don't don't vomit here
with it says embryology and all
kind of stuff and so forth.
I hate it too.
But these are scleral tomes,
occipital four and C.
One and C.
Two.
It so happens that in lower vertebrates there's a
thing called the pro atlas in between
occipital four and C.
One.
Okay.
And it is a separate bone in a lot of lower
vertebrates in men,
it goes over and joins up with occipital four.
Okay.
But this pro atlas happens to give off the top
part of C.
One.
The articular surface is a little bit of the spine ist tip
and the ost terminally the little thing
at the top of C.
Two.
Okay.
That's important.
Also it can give off a bunch of other little obstacles
located in about here,
just off of C.
One,
you can see if this thing doesn't get amalgamated properly with
occipital for little bones could result.
Now the body of C.
One is actually the dens of C.
Two.
There is no body of C.
One,
right?
So C.
One,
dens,
I mean C.
One body is actually the dens of C.
Two,
and the rest of C.
Two comes from Clara tome C.
Two.
So you see,
it's not as difficult as it looks.
Remember the pro atlas,
because I'm going to show you what we call,
we've called the osce terminally then everybody
calls it that and pro atlas obstacles and
that's what we're going to deal with next.
These are just a bunch of little obstacles that
occur primarily Superior to
the anterior arch of c.
one.
They're usually small,
they may may maybe multiple or single
have no particular significance,
no particular significance.
Okay,
Little obstacles that you see above the anterior arch of c.
one.
Some of them look very big like this,
still no significance.
And we've just called those pro atlas
obstacles.
Others call them remnants of sort of an occipital
vertebra,
but you can expect them to occur.
I mentioned them because they I think they must
be differentiated from this thing which sits right at the
top of the dens and
that's the osce terminally normal.
If you take a lot of polyrhythms for ear
problems or just good old open mouth of non toys.
You'll see it in kids.
It stays there till late childhood.
It goes by adolescents usually sometimes earlier,
sometimes later and it sits on top.
But why is this important?
Well,
I'll tell you why it's important because if
you collect enough cases,
here's one with a small mosque.
Terminally normal,
dense.
Here's one in the second slide.
A bigger office.
Terminally with a dense that looks a little smaller.
Now,
I prefer to start calling it at this
stage.
And certainly by the third slide,
the auditorium which we feel is an
overgrown osk terminally
almost always associated with some degree of
hyperplasia.
Of the dense.
So we have the pro atlas obstacles up front
which do nothing.
I think then you have the ost terminally on
top of the dens and then you have this
thing perhaps getting bigger in some patients with the
dens getting smaller and you will have
then the old on toy.
Um which I can you may want to think of it
certainly I think of it as an overgrown osk
terminally now this is the thing that gives you a lot of
trouble here are four cases
of us.
Golden toity.
Um Here's one that we looked at on the previous slide,
right on top of the dens.
Hypoplastic dense here,
funny looking.
These are funny looking bones,
triangular hypoplastic dens,
there's the body of C.
Two weird
looking.
No dens at all.
Weird looking.
and here's one here that is anti really
displaced with C.
One hypoplastic dens.
These are all sewed on toy idioms
also hold on tightly I guess for latin,
right?
When it becomes for texas it's comes
for for a lantern.
It's I guess.
And but you have
hyperplasia hyperplasia of
the dens and you have instability of the
spine and this toronto medium takes
up space in the spinal canal and especially
with posterior dislocation,
it will encroach upon the medulla
and so forth.
And this patient had a lot of serious
neurological sequelae.
Was a six year old child.
So what do we want to remember from this series of slides?
The also don't odium we feel and I
find it at least convenient to think of it this way is an
overgrown Osk terminally which is a normal part of
C.
Two If you see it.
So that the bigger it is,
the more hyperplasia of of the dens you
have.
It is often very bizarre in configuration
and it's very frequently if not almost always
associated with some instability at the
C12 area often profound.
And cord compression does occur and
this thing has to be looked after.
It's just as serious as an as instability
with trauma but it's all anomaly.
Okay and here's a bigger one
and we'll come back to this one later on.
This is poster and this kid,
this kid,
this kid came in for an accident and we
discovered this and they spent all these politicians deciding
whether this was a fracture or not.
The tip off was this,
and we'll come back to this later.
Well,
that's I don't have it in there.
I think maybe I have it on the next one.
Okay.
The tip off was that he had other anomalies,
but that was another episode on totem,
and I'll come to it a little later in the slides.
Now,
the big question is,
how do you tell the us?
Hold on,
Tony um from a fracture.
Well,
we'll go back to this diagram,
but it's much simpler.
Now,
basically,
if you have a high defect,
in other words,
high up in the dens,
you don't have to worry that's going to be an anomaly.
It may be unstable,
but it's an anomaly.
If it's a low defect through Level two,
then you have a fracture.
What do I mean by this?
Mhm.
Here's our friend again.
You see,
here's C two body,
here's the dense hypoplastic,
this is a high defect fractures of the dense occur through
this Level Level two.
So,
if you're up at the top,
if you're up at the top,
you probably have a congenital anomaly.
Okay,
so that was point number one,
all this kid had was a unilateral
fracture of C.
Two and that's what was given him pain,
but this was unstable and he needed to be fused for
this anomaly.
But nobody picked this up.
He was 14 years old before I ended up in this car accident
and then a whole lot of time was spent in deciding whether this was
fractured or not.
A clue here was that on frontal view and we're going
to come back to this.
This looks very weird And you can believe that caused him a
lot of trouble about 11:30 PM on Friday.
I mean,
they even got polyrhythms at that time.
That's how much trouble it caused them.
And it was all anomaly and you'll see later
why it should have been anomaly.
But the point is,
if it's high and there are other
anomalies,
it's an anomaly almost for sure if it's
low and everything looks good like in this
infant,
you have a fracture through the base of the dense
same thing in an older child and an adult.
The problem,
however,
is is that a lot of un united,
dense fractures tend to have a smooth surface
between them.
And how do you tell the difference if the defect is
low between anna Don toyed fracture,
UN united and an auditorium.
And this is basically what we use.
If the superior article looks like a normal
dense and there are no other anomalies present,
then chances are you have a fracture,
if the thing looks peculiar and doesn't look
like a normal dens and other anomalies are
com are,
are present.
Then you have an old inventory.
Um,
with a hypoplastic,
dense,
Just pause there for a minute and repeat that
you're not going to run into trouble with a regular acute
fracture through the base of the dense.
I mean you may have trouble picking it up and so forth,
but that's not going to be the problem.
The problem is going to be in the old un united fracture
that moves and develops sclerosis and sort of
a pseudo are throw sis and it's low.
How are you going to distinguish that from a low
congenital defect with a lot of hyperplasia of
the dense.
This is the way if it looks like a dense
and there are no anomalies,
then chances are it's an old fracture.
Now we can summarize it this way.
Three cases our friend who came
in in the automobile accident and I
showed you the frontal view and look at this plane film.
Look at that.
See one,
This whole area looks anomalous.
This was high an
anomalous.
It's clearly an anomaly.
But look at this one.
It's low.
There is the body of C.
One.
Low.
Is this anomaly or not.
If we look at it,
see one is underdeveloped but the main thing
is that this obstacle,
the superior optical does not look like a
normal dans anymore.
It's triangular.
It's weird looking that favors anomaly and it
was an anomaly.
Now here's a patient with a past history of
trauma and Adan toyed fracture and
shows up later on with this picture.
Now,
here's this thing,
it is low,
there is the body of C.
Two.
Is this an anomaly or a fracture?
This still looks like a dense and if you
look at the plain films,
it's hard to see the fragment.
It's a little d mineralized,
but the plain films show no anomalies of any
other kind.
This should be and was a low
defect secondary to an old un united
fracture with a suit.
Our throats is there and an unstable spine.
Well,
both of them are unstable,
but the point is that this is the result of old
trauma.
This is anomaly.
This is clearly anomaly because of the high defect.
Okay,
I'm gonna scoot along here because we're probably
getting close to our time.
This is the weirdest one of all.
And if you don't appreciate this one,
you're just gonna you're gonna make a mistake on the first film,
you're gonna think that this is the dens after I told you or
the S hold onto medium or something when you have
no dents.
C one gets awfully big
entirely.
It over grows,
This is the anterior arch of c.
one.
Look at the alignment here,
look at the poster arch of c.
one this is really kind of unstable,
but it's not as bad as if you had an episode on titanium
in there because there is no assault on toy Diem here,
there's nothing there.
If you have that extra awesome toronto sodium,
it takes up space in the spinal canal.
This is no dens at all.
This is nothing with flexion.
Watch this thing here with flexion.
You'll see now that this is C.
One,
this is C.
One and there is no dense.
This is complete absence of the dense
and here it is on frontal view,
nothing there.
So to summarize this,
we can use this diagram and say that
anomalies of the dense have a wide
spectrum number one,
you can have normal number two,
you have the oss terminally number three.
When the oss terminally gets big,
it becomes the episode on titanium and you usually have
hyperplasia of the dens
unstable spine here,
cord compression.
Then you may not have the also an anti sodium at all.
Just a hyper plastic dens,
you may or may not have instability there and
then you may have no dens and no also don't odium
and that's usually an unstable
situation.
So from here on in is abnormal one
way or another and you have instability
and this is probably the worst situation of all the
episode on toity.
Um on the basis of this diagram would be an
overgrown Osk terminally now everyone
might not agree with that,
but I find it convenient to think of it that way.
And it helps me understand these
C.
One anomalies.
C.
Two.
Anomalies of the dens.
This next thing is really not so much science
as I saw it before and there's nothing that could
look like it again.
So it's got to be anomaly.
If you see this on frontal view,
if you see this on frontal view then you ought to
think of anomaly.
I'm not gonna go into detail.
It looks like that looks like a bunch of lego
toys sort of stacked correct on one side and
incorrect on the other side.
And if you draw a diagram you can have it look like this
and it'll look like that and don't spend a lot of
time looking at it.
Just kind of get the idea there are triangles,
squares and everything in there because we have
three cases of this that I want to show you there and
there and there and when it looks
like that,
that's anomaly you see.
So whatever you see on the lateral view,
if you're concerned about it and you pick up this kind of
stuff on the frontal view,
you go back and say which is what they should have done that friday
evening when they saw that kid with the big auditorium
displaced posterior lee should have said this is the
weirdest looking thing I ever saw.
I mean you couldn't fracture it this way.
This requires an exacto knife to
do this right or a little bolt
of lightning and about the third trimester,
right?
I mean there's no way to get this thing out
of a fracture that's got to be kind of done a different
way.
So there's no science to it at all.
This is step like deformities.
A.
C one C two segmentation abnormalities.
It looks anywhere near this.
It's anomaly.
And that's all I want to say about that.
And we'll be left with one topic then.
Occipital ization of C.
One,
which I think you're all familiar with.
But how do you tell it?
How does it result?
Well,
occipital ization of C.
One is really just a failure of proper segmentation of the
base of the skull from C.
One.
This is how I like to first detected and many
times you will detect it on the scale film.
First of all things look pretty crowded up there,
don't they?
And you're looking for c.
one and c.
two.
Well,
fortunately this one came out of the exam at
labeled,
you see.
So it's easy.
But sometimes out of our excitement,
they're not labeled.
And then I would say it looks crowded.
You can't find your landmarks.
And I want you to note here that C.
Two looks kind of big and plumpy.
That's good.
But it's also bad.
I want you to concentrate on that.
There's C.
One of course the poster arch is
fused because it ought to look like this.
There's C.
One.
You ought to be able to pick it out to pick out the Adan toyed.
Okay,
so first of all,
you ought to be able to pick out,
see one at the base of the skull.
But the most important thing I like to look for
is find C.
Two.
Don't look for C.
One.
Find C.
Two.
C.
Two Almost always is the biggest arch
and spineless process up there.
And why do I say that?
Because if you find the biggest one
up there and it's the first one,
you see something's wrong.
See the first one you see should be smaller,
it should be c.
one.
It should look like this.
C.
one is smaller than c.
two.
If you see the big one up there,
something's wrong and then start looking around and it does look crowded.
It's occipital.
Ized.
So that's one good way to find it.
If you want to confirm it.
The biggest one up here is C.
Two flex them.
And when you flex them it will not separate right from
the basic maybe fibers.
It may be unilateral,
it may be bilateral,
it maybe bony,
there may be no C.
One arch at all.
The first thing though it's crowded,
you can't find your ordinary landmarks.
And the second thing,
the biggest spine ist process that you visualize up
there often will be,
Well the one you visualize will be the biggest and that
should be c.
two.
And that should be abnormal.
Here's another thing that you may not.
Well this is normal to show how it separates off the base of the
skull.
Here's another thing that you might not appreciate.
And I think over the last eight or
10 years I've been able to pick up
three of these on the basis of skull films done for
something else.
Unilateral or bilateral eccentric
stenosis of the foramen magnum.
You notice here is a good finding,
especially with unilateral occipital ization
because normally the foramen magnum should look like
this.
Nice and symmetrical very seldom is an asymmetric.
If it's asymmetric like this you have
unilateral occipital ization.
Maybe bony unilateral on one side fibers on the
other but it's abnormal.
So the flexion is good.
You can see it on the town's view initially.
You suspected because of the crowded appearance
at the the occipital
cervical junction and the inability to
define your C.
One arch anti really post early in the dens and so
forth.
So that's how you pick it up.
You confirm it with reflection.
And then you usually go onto
tomography or and or maya la graffiti to
demonstrate any number of associated
abnormalities.
And of course they may have arnold chiari malformation on the
monogram.
But I'm going to show you too.
Or three plain film findings that you
frequently find with this.
Number one.
Obviously the one of concern is in vaginal
ation of the dance into the frame and magnum well above
this line which I don't think is anybody's in particular.
I can't I never could remember those lines.
And anyway I think they all come from the hard palate.
But this line is just to show you where the frame and magnum
is.
I'm not saying it's anybody's in particular.
The whole thing is shoved up there and the whole spine is
sort of displaced posterior lee.
Now here's hyperplasia of the dense.
If you want to take this back to our dens
anomalies this is hyperplasia with
Noah's opponent Odium.
Okay.
But it's also associated this time with
occipital ization because you see see one is bound to
the base of the skull and the anterior arch now is
right beneath the tip of the cli vous and
often it is even more posterior.
So basilar imagination hyperplasia
or dysplasia if you like.
Of the dense because hyperplasia may be too
limiting.
And then fusion of C.
Two and C.
Three.
All this says is that if you find occipital
ization you must go on and check
it out for these other problems.
Now this in itself is not a big problem.
It's just to sort of round up the discussion.
This is the thing that you want to make sure is not
present.
In other words imagination.
Pressing on the medulla.
Do you have arnold chiari malformation?
You may do maya lager afi in a patient like
this occipital ization as you know often
presents with peculiar neurologic findings.
They may think they have some dim eliminating disease.
They may think they have syringa Malia may think
they have a poster of faucet tumor.
So it is important because the guy,
hopefully the guy that should know most
about or the girl,
pardon me,
I've got a girl in the front row here.
Gotta be careful.
I am old fashioned,
I still say guy.
Uh uh so I can't get
to say just people or person.
Anyway that'll all change eventually.
We'll get back to guy and girl which is the only way
gang.
And I don't
like this business of uh of a person
to neutral.
I like positive and negative.
But anyway that's a side point and so forth.
So the guy or the girl that ought to know
most about this ought to be the radiologist because
you may pick this up and always watch for that
when they come in with peculiar neurologic findings.
Always look at the upper cervical spine on a
skull film and you'll be surprised at how much you see
there,
we can douse that.
And I would like to summarize a few points for you here before
closing because I want to reiterate a couple of things
that are important.
Number one,
C one and C.
Two are prone to anomalies.
So you see if you think you have
an injury at C.
Four and C.
Five or C.
Six,
you probably have an injury at C.
Four,
C.
Five and C.
Six and C.
Seven and so forth.
You know there are anomalies that occur there.
But if you think you've got an injury at C.
One and C.
Two.
Be careful because anomalies are very common as you
all appreciate these things are difficult for you to pick up
often or did differentiate.
And so if you get that orientation at least you'll
stop yourself and say gosh is this an
assault on toity?
Um and then you'll go and look it up if you don't remember.
It's hard to remember all this stuff because it's kind of it's
embryology,
it's weird looking and so forth.
The general orientation is important.
And I would ask you then finally if you're going to
use the poster cervical line in those
pseudo dislocation use it under the proper
circumstances.
Do not use it if C.
Two is not offset on C.
Three.
If it is,
the line is very helpful.
If you follow the criteria that I outlined earlier
and don't have to move the spine around at all.
Just take the first film you get if it's offset,
measure it on that one.
And finally if you can't make up your
mind and you're in doubt don't slough it off as
a normal.
Say it may be abnormal.
It may be normal but we better make real sure
that it's abnormal and then do whatever you have to do
to define whether it's normal or not only
depend on that line when you're sure that everything is good.
A good lateral,
you know where your measurements are it's offset and it comes
within normal range I can tell you that most
cases if not all of them you'll be okay but if
there's any doubt do something else.
Don't rely on it.
Get another film.
That's the easiest thing to do.
Get another film.
You'd be surprised how that bails you out in many
cases.
Thank you.
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