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Terry R. Yochum DC, DACBR, FICC

Alicia M. Yochum RN, DC

Wonders of the

Upper Cervical Spine

7 Wonders of the World

Original

1. Great Pyramid of Giza

2. Hanging Gardens of Babylon

3. Statue of Zeus at Olympia

4. Temple of Artemis at Ephesus

5. Mausoleum at Halicarnassus

6. Colossus of Rhodes

7. Lighthouse of Alexandria

Natural

1. Grand Canyon

2. Great Barrier Reef

3. Harbor of Rio De Janerio

4. Mount Everest

5. Aurora Borealis

6. Paricutin Volcano

7. Victoria Falls

APOM APOM

Bad Positioning

Tuck Chin!

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Incisors

Tilt Head Back!

APLC

Lateral

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Vertex/ Submental Vertex Vertex/Submental

Nasium Base Posterior

Incisor Cleft C2 Right Rotation

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C1 Posterior Tubercle

T1:

• Fat-White/High

• Water- Dark/Low

AXIAL>>>>>>

T2: Water- White /High Fat- Dark/Low

7 Categories of Bone Disease

•Congenital

•Arthritides

•Trauma

•Blood (Vascular)

• Infection

•Tumor

•Endocrine

•Soft Tissue

Failure of

ossification vs.

Traumatic

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Change in

angulation

14mm

Translation

Synchondrosis or Os Odontoid?

http://openi.nlm.nih.gov/detailedresult.php?img=2769451_1757-1626-

0002-0000008530-003&req=4

http://www.tecserena.com/KlinStud_01_e.html

Down’s Syndrome- Trisomy 21

20% of patients

are born without

a transverse

ligament

Atlanto Dental Interval (ADI)

Predental Space

Child: 1-5mm

Adult: 1-3mm

May become V shaped in flexion-measure in the middle of the ADI

Spinolaminar Line

Posterior Cervical Line (PCL)

Listhesis of a vertebrae

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Spina Bifida Occulta C2 Paraodontoid Notches

OccipitalizationAgenesis of the Posterior Arch of C1

Agenesis of the Posterior Arch of C1

• Megaspinous Process of C2

C2/3 Congenital Block Vertebrae

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Arnold Chiari Syndrome- Type 1 • Type 1 is most common

• Cerebellar tonsils displaced through foramen magnum

www.radiopaedia.org

<3mm: Tonsilar Ectopia

3-6mm: Indeterminate, Correlate clinically, look for syrinx

>6mm: Arnold Chiari Type 1

Osteoarthritis

Narrowing of the Atlanto-

Axial Joint with sclerosis

and osteophytosis

DISH

1. Flowing hyperostosis of at least

4 levels

• If less then 4 levels it has not

progressed yet (Frome Fruste)

2. Relative preservation of the disc

spaces

3. Relative preservation of the

apophyseal joints and sacroiliac

joints

• Does not always decrease motion

• Associated with Diabetes Mellitus

Ossification of the Posterior Longitudinal

Ligament (OPLL)• Canal stenosis

• Signs of myelopathy – Any neurological deficit to the spinal cord

• Upper motor neuron signs (weakness, spasticity, clumsiness, altered tonus)

• Pathological hyperreflexia and inverted Plantar reflex (positive Babinski sign)

• Sensory deficits

• Bowel/bladder symptoms and sexual dysfunction.

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Inflammatory Arthritides

•C1/2 articulation is synovial

•Synovitis is associated with inflammatory arthritides

•Causes erosions

•Most Common

•Rheumatoid:35%

•Less common in

•Psoriatic: 8-23%

•Ankylosing

Spondylitis: 2-15%

•Reactive: <2%

http://www.rad.washington.edu/academics/academic-sections/msk/teaching-materials/online-musculoskeletal-radiology-book/axial-arthritis

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Ankylosing Spondylitis

Psoriatic Arthritis Hydroxyapatite Deposition Disorder

• General Considerations

• Calcification in a tendon, bursa or

other periarticular ST

• AKA: calcifiying tendonitis

• Clinical Features

• Acute pain, Tenderness

• Swelling – Increased retropharyngeal

soft tissue

• Deposition of hydroxyapatite

• Dystrophic Calcification

• Location

• MC is shoulder- supraspinatus

• Spine

• Longus colli

• Nucleus Pulposus

HADD

http://www.appliedradiology.com/Issues/2012/08/Art icles/AR_08-12_Tehranzadeh/Imaging-of-crystal-deposit ion-disease.aspx

Reteropharyngeal Soft Tissues

• C2-7mm

• C7-22mm

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ATLAS

Jefferson’s fracture

Four part comminuting at the ring of the atlas

Yochum & Rowe “Essentials of Skeletal Radiology”

ATLAS

Jefferson’s fracture

Vertical loading in which the

force is transmitted through

Skull vertex

Occipital condyles

Lateral masses

Foreman & Croft “Whiplash Injuries CAD Syndrome”

Offset of lateral masses >7mm

ATLANTOAXIAL ALIGNMENT. A. Normal Alignment

NORMAL

Overhanging Edge

www.learningradiology.com

Offset of lateral masses >7mm

AXIS

Hangman’s fracture

Synonymous with traumatic

spondylolisthesis

Bilateral disruptions through the

pedicles of the axis

33% associated with additional

fractures Panjabi & White “Clinical

Biomechanics of the Spine”

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Hangman’s fracture

Yochum & Rowe “Essentials of Skeletal Radiology”

Hangman’s Fracture

Type 1

Upper Dens

Rare

Stable

Type 2

Base of the Dens

Most Common

Unstable

High Risk of Non-

Union

Type 3

Body of the Axis, Facet

Stable/Unstable

Best Prognosis for

Healing

Dens Fracture- 3 Types

www.pua.edu.eg

Type II

http://www.radiologyassistant.nl/en/p49021535146c5/spine-cervical- injury.html

http://www.radiologyassistant.nl/en/p4

9021535146c5/spine-cervical-

injury.html

Guillotine effect

Isolated rupture of the transverse ligament with an intact odontoid

Cord occupies 1/3 of canal

Steel’s Law of 1/3’s

Need 30% damage to cord before symptoms present

Chronic rubbing?

Yochum & Rowe “Essentials of

Skeletal Radiology”

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Guillotine effect

Yochum & Rowe “Essentials of Skeletal Radiology”

18% Reduction in canal size

Torticollis• Ipsilateral muscular spasm or fibrosis

• UL shortening of SCM may contribute

• Often follows injury to C1/2

Flattening of the cervical

curve could indicate

muscle spasm in a

non-degenerated spine.

55 YEAR OLD FEMALE PATIENTCHRONIC HEADACHES – NO POSITIVE ORTHO OR NEURO SIGNS,

LONG-TIME CHIRO PATIENT

Courtsey of Dennis P. Molloy, D.C.

Vernon Hills, Illinois

Virgil Strang DC

Metastatic Carcinoma

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31yo with neck pain 65-yo male with neck pain

Permeative destruction of the C2 body with preservation of the endplate below

Differential

Diagnoses?

60-yo male with neck pain

Lytic destruction of the C3 vertebral body

Preservation of disc spaces above and below

Infection or tumor?

Aneurysmal Bone Cyst

http://www.tumorlibrary.com/case/detail.jsp?image_id=4967

Neurofibromatosis- Type 1

• Enlarged intervertebral foramen

• Pressure erosion

spineuniverse.com http://radiology.casereports.net/index.php/rcr/article/viewArt icle/708/1042

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Schwannoma

• Tumor of the nerve sheath

• Most common in head and neck

and nerves of the upper

extremity

• Most are benign

Eagles Syndrome

•Pain in the oropharyx and face from elongated styloid

process or calcified stylohyoid ligament

•Manifests at nagging dull, long term ache in throat,

sometimes radiating to ipsilateral ear and sensation of

foreign body in throat.

• Dysphagia

•First thought to be related to Tonsillectomy

• Responsible for formation of scar tissue around styloid apex

Retropharyngeal Hematoma

• Increased Retrophareal space

• Blood

• Pus

• Cells

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