The Big One

Basically the whole imaging class in one flashcard set.

On what factors are imaging decisions for the cervical spine based?

Trauma MOI and whether there is neurological involvement

According to the Canadian C Spine Rule, at what age is imaging indicated regardless of other factors?

Older than $65$

What are the four components of the Canadian C Spine Rule?

Older than $65$, traumatic MOI, extremity paresthesia, and ability to rotate $45$ degrees left or right

Which midline location must be free of tenderness to meet the Nexus Low Risk Rule?

Posterior midline

List the five criteria of the Nexus Low Risk Rule.

No tenderness of posterior midline, no focal neurologic deficit, normal level of alertness, no evidence of intoxication, and no painful distracting injury

Which imaging modality is considered best for viewing cervical spine fractures?

Multi-Detector CT

What is the purpose of the Swimmer’s View in cervical imaging?

Better visualization of the cervicothoracic junction

What is the typical mechanism of injury for Odontoid Fractures in young people?

High impact trauma or MVA

What is the typical cause of Odontoid Fractures in old people?

Low energy fall

Which Odontoid fracture type is most common?

Type $2$

Describe the fracture line of a Type 2 Odontoid fracture.

A perfect horizontal break at the bottom of the odontoid

Type 2 Odontoid fractures often lead to what type of weakening?

Osteoporotic weakening

What is associated with Odontoid fractures in terms of patient outlook?

High morbidity and mortality

What are the strongest indicators of Odontoid Fracture in older adults?

Midline tenderness, focal neurological deficit, and indicators of trauma on the head or face

What factor strongly predicts survival versus mortality within the $1^{st}$ year after a type 2 odontoid fracture?

Frailty of older adults

Contrast the uses of CT and MRI in cervical spine evaluation.

CT is best for bony elements, while MRI is best for neural and soft tissues

Is it common for patients with Atlanto-Axial Subluxation (AAS) to be asymptomatic?

Yes, many are asymptomatic for years

What is the maximum normal measurement for the Anterior Atlanto-Dens interval?

$$3 mm$$

Which systemic condition is associated with increased cervical instability?

Rheumatoid Arthritis

How much higher is the mortality rate for patients with AAS compared to those without?

Up to $8 \times$ higher

What must be checked during a scan exam for suspected cervical instability?

Neurological tests

What is the recommendation regarding the Sharp Purser test in the notes?

Don't do it

Which imaging modality is best to visualize cord compromise in AAS?

MRI

What imaging technique can be used to see osseous displacement in the cervical spine?

Flexion-extension radiographs

How do Biologics and DMARDs affect cervical instability?

They can help prevent new instability lesions

Why does taking DMARDs paradoxically correlate with a risk of instability?

It indicates the disease process has become severe

List five risk factors for Rheumatoid Subluxation.

Female, low bone mass density, young at diagnosis, steroid therapy, and previous joint surgery

What severe condition may result from cervical subluxation?

Basilar invagination

List six conditions that Basilar Invagination may accompany.

Chiara Malformation, Down Syndrome, Klippel Feil Syndrome, Osteogenesis Imperfecta, Rheumatoid Arthritis, and Paget’s Disease

What is the prognosis for basilar invagination?

Poor prognosis

Which group of patients is at high risk for cervical instability?

Patients with connective tissue disorders

What are the primary indicators of cervical subluxation?

Neck pain accompanied with non-mechanical symptoms suggestive of neurological involvement

List five neurological symptoms suggesting cervical subluxation involvement.

Paresthesia, gait difficulty, vertigo, diplopia, and dysphagia

Define Lhermette’s Sign.

An electrical shock sensation with cervical flexion

What is the diagnostic utility of Flexion-Extension view radiographs in the context of management?

They are not that great and don’t change management approach

Which modality is best for identifying ligamentous injury in the C-spine?

MRI

List six degenerative changes MRI will find in the cervical spine.

Disk height loss, loss of signal from desiccation, annular fissures, osteophytes, end plate changes, and herniations

Why is loss of IV disc signal on MRI considered part of the natural course?

They will lose signal no matter what as part of aging

At which levels is Z joint degeneration most common in the C-spine?

C2 through C5

What does loss of paraspinal musculature in the C-Spine indicate?

Indicative of poor outcomes over the course of life

Define Klippel-Feil Syndrome.

Congenital fusion of one or more segments

At which levels is Klippel-Feil syndrome most common?

C2 through C5

What activity should Klippel-Feil patients avoid?

Contact sports

What symptoms are associated with the multi-level involvement of Klippel-Feil?

Dizziness and balance issues

At what levels does cervical radiculopathy most commonly occur?

C5 through C7

What is the usual origin of cervical radiculopathy?

Bony origin

What is the modality of choice for diagnosing cervical radiculopathy?

MRI

List the four tests in the Clinical Prediction Rule for cervical radiculopathy.

Upper Limb Tension Tests, Ipsilateral Rotation to $60$ degrees, Reduction of Symptoms with Traction, and Spurling’s Test

In which dermatomes does sensory loss in the upper extremities often occur?

C6 and C7 dermatomes

What muscular change is common post-radiculopathy?

Decrease in multifidus cross sectional area

Which Upper Limb Tension Test offers the highest diagnostic value?

Median Nerve ULTT

What are the common demographics for cervical myelopathy?

Men more than women, usually around $64$ years old

At which levels does cervical myelopathy usually occur?

C5 and C6

List five neural involvement signs seen during a scan exam for myelopathy.

Motor deficit, thenar atrophy, spasticity, impaired gait, and myoclonus

How does step pattern change if cervical spinal cord compression progresses to higher severity?

Shorter, slower steps

What is the 15s Grip and Release test used to evaluate?

Ability to open/close the hand fast, often impaired in cervical myelopathy

Define the Finger Escape Test.

Abduction or flexion when trying to sustain finger extension and adduction

What reflex status is common in cervical myelopathy patients?

Hyperreflexia

Besides the cord, where else have changes been shown to occur in cervical myelopathy?

Motor areas of the brain

What is cervical spine stenosis often caused by?

Osteophytosis at the disc-vertebra junction

List five Myelopathic Tests used in cervical stenosis assessment.

Hoffman’s Reflex, Babinski, Clonus, DTRs/MSRs, and Inverted Supinator

What do inverted neurological responses at muscles suggest?

Central involvement

Define the Tromner Sign.

Flicking of the $3^{rd}$ DIP into extension

What does Tromner Sign suggest?

Central involvement

Contrast the value of CT Myelography and MRI for cervical stenosis.

CT shows interface of neural elements via contrast; MRI shows signal of the cord and CSF

Which two ligaments may see buckling in cervical stenosis?

Ligamentum flavum and posterior longitudinal ligament

What can Electrophysiologic testing help determine when used with MRI?

Function of neural tissues

In which populations is Posterior Longitudinal Ligament (PLL) Ossification more prevalent?

Asian populations and those with Ankylosing Spondylitis

PLL ossification increases the risk of what condition?

Cervical myelopathy

What is the most common presentation of PLL ossification?

Cervical myelopathy

On which modality is PLL ossification best demonstrated?

MRI

Is PLL ossification more common in men or women?

Men

What change is seen on MRI in ligamentous structures post-whiplash injury?

Higher signal intensity

Which modality is best for ligamentous visualization after whiplash?

MRI

What muscular changes occur in the neck following Whiplash Associated Disorders (WAD)?

Increased fatty infiltrate of posterior neck musculature and increased CSA of anterior neck musculature

How does increased fatty infiltration affect WAD outcomes?

Leads to lower functional scores

Patients with Ankylosing Spondylitis are at increased risk for what in the C-spine?

Instability and lower C-spine fractures

What is Os Odontium?

Anatomical variant of an extra bony fragment at the C2 spinous process

Define Adjacent Segment Disease.

Complication following spinal fusion

With which spinal fusion level does Adjacent Segment Disease most commonly occur?

C5-6 fusion

On what modality is Adjacent Segment Disease demonstrated?

Radiographs

Where does a Cervical Rib typically arise from?

The C7 transverse process

A Cervical Rib is a risk factor for which two conditions?

Thoracic outlet syndromes (TOS) and brachial plexus injuries

Which modality is best for TOS surgical planning and diagnosis?

MRI

Which two modalities can be used to diagnose a Pancoast Tumor?

CT or MRI

Describe the radiographic appearance of a Pancoast Tumor.

Lack of pulmonary air and shadow at the apex of the lung; atypical radio-opacity

How does a Pancoast Tumor usually present?

Shoulder pain and medial scapular pain

What is the typical demographic for a Pancoast Tumor?

~$50$-year-old men with a smoking history

Does a Pancoast Tumor present with typical radicular symptoms?

No; Spurling’s won’t relieve symptoms, but they will have positive neurological symptoms

Define Horner’s Syndrome symptoms in the context of Pancoast Tumor.

Drooping eye and lack of sweat on one side of the face

List four signs that increase suspicion of Pancoast Tumor.

Constant severe pain, loss of sleep, history of smoking, and reduced function

What is the number one risk factor for Pancoast Tumor?

Smoking

Which shoulder radiographic views best show the relationship of the humeral head and glenoid?

Axillary View and Westpoint View

What is always the recommended first line of imaging for the shoulder?

Radiographs

What is the value of Ultrasound in shoulder pathology?

Diagnostic value for rotator cuff pathology, equivalent to MRI

Define the Buford Complex.

Cord-like medial glenohumeral ligament originating directly from the superior labrum

What is a Sublabral Foramen?

A sulcus between the anterosuperior portion of the labrum and the glenoid articular cartilage

What is an Os Acromial?

Incidental finding on radiographs that may contribute to impingement

What is the typical demographic for Proximal Humerus Fractures?

Older women with osteoporosis and falls

When is MRI used for a Proximal Humerus Fracture?

If rotator cuff integrity is in question