Congenital anomalies and degenerative conditions of vertebra

ANOMALIES AND DEGERATIVE CONDITIONS OF VERTEBRA

1. CT STUDY OF CONGENITAL ANOMALIES, INFECTIONS AND DEGENERATIVE CONDITIONS OF SPINE PRESENTED BY : DR. B.BORTHAKUR PROFESSOR AND HEAD, DEPT OF ORTHOPAEDICS, SMCH

2. CONGENITAL ANOMALIES OF THE VERTEBRAL COLUMN Spina bifida occulta Coronal cleft vertebra Butterfly vertebra Hemi vertebra Block vertebra Sacralisation of 5 th lumbar vertebra Lumbarisation of 1 st sacral vertebra

3. Spina bifida occulta Cause : incomplete fusion of halves of the vertebral arches resulting in midline defect usually in lumbosacral region Feature : It varies, but generally the small bones (vertebrae) that make up the spine don’t form fully and may have gaps between them.

4. Computed tomography (CT) scan in the axial plane of the cervical spine showing the defect of fusion of spinous process of T1

5. Coronal cleft vertebra in an infant Coronal cleft vertebra : Cause : persistence of dorsal and ventral ossification centres separately Most common in lumbar spine

6. Butterfly vertebra distance. Butterfly vertebra

7. BUTTERFLY VERTEBRA

8. Hemivertebra Cause : failure of one of the chondrification center to appear and subsequent failure of half of vertebra to form Types : based on location lateral, dorsal and ventral Feature : defective vertebra produce scoliosis Most likely to cause neurologic problems HEMIVERTEBRA

9. HEMIVERTEBRAE HEMIVERTEBRA

10. Block vertebra Cause : embryological failure of normal spinal segmentation Radiologic features : characteristic triad of hypoplastic vertebral body(wasp-waist deformity, C concavity), small/ abscent disc, variable posterior arch fusion

11. n. Acquired ve rtebral body fusion of C5 and C6 . Block vertebra with congenital fusion of C3 & C4 . Note the presence of a “waist” at the site of fusion. BLOCK VERTEBRA

12. Spinal Infection Bacterial spondylitis/spondylodiskitis Pyogenic spondylitis is usually caused by hematogenous spread of infection. Sources of septic embolism are most commonly from the genitourinary tract, followed by skin and respiratory infections. Bacterial spondylitis may also be caused by direct extension from penetrating trauma, surgical intervention, or from adjacent infected structures.

13. Patient presentation is variable in patients with pyogenic infections, but typically involve focal back pain, myalgia, and muscle spasm. The causative organisms are predominantly gram-positive, with Staphylococcus aureus as the most common bacterium. Enterobacteriaceae comprise approximately 30% of cases, with other less common causative organisms including Staphylococcus epidermidis, Haemophilus influenzae, and Streptococcal species. Escherichia coli is the most common gram-negative source . Pseudomonas is commonly seen in intravenous drug abusers. Salmonella is relatively more commonly encountered in patients with Sickle cell disease

14. Radiographic evidence of osseous demineralization requires 30% to 40% loss of the osseous matrix, which may occur two weeks after onset of clinical symptomology. CT is not considered to be of much utility for diagnosis of intervertebral disk infection. However, CT is often utilized in image guidance to obtain samples of infected specimens, for both osseous and non-osseous tissue. The mainstay to diagnose and assess the extent of disease involvement is with MR imaging. MR is the most sensitive imaging modality to assess for early osteomyelitis . The earliest imaging finding (across all imaging modalities) is osseous bone marrow edema.

15. Axial CT demonstrates destructive changes involving the T2 vertebral body

16. Pyogenic Spondylodiskitis with posterior mediastinal abscess. Sagittal CT demonstrates osseous destruction of the endplates at the T2 ,T3 level with reactive sclerosis of the adjacent vertebral bodies

17. Tuberculous spondylitis/spondylodiskitis The thoracolumbar junction is the most commonly affected segment of the spine involved in tuberculous infection. Cervical and sacral spine involvement is less common . Spinal tuberculosis usually begins in the anterior aspect of the vertebral body, either at its superior or inferior margin. The infection typically spreads in a sub-ligamentous fashion, usually deep to the anterior longitudinal ligament and may traverse multiple vertebral levels. The route of disease spread generally occurs anterolaterally. In contradistinction to pyogenic diskitis, tuberculous disease spares the intervertebral disk, as Mycobacterium tuberculosis lacks the proteolytic enzymes to break down the disk

18. Axial CT scan shows the fragmentary bone pattern and large paraspinal soft tissue abscesses with initial calcification of the wall TUBERCULOUS SPONDYLITIS

19. Tuberculous spondylitis and pyogenic spondylitis   Tuberculous spondylitis and pyogenic spondylitis  : para- or intraspinal abscess : presence favors tuberculous spondylitis  abscess wall : pyogenic spondylitis walls are thick and irregular tuberculous spondylitis walls are thin and smooth postcontrast paraspinal abnormal signal margin pyogenic spondylitis margins are ill-defined tuberculous spondylitis margins are well-defined abscess with postcontrast rim enhancement involves the disc in pyogenic spondylitis involves vertebral intraosseous in tuberculous spondylitis number of vertebral bodies involvements pyogenic spondylitis tends to only involve no more than 2 vertebral bodies tuberculous spondylitis involves multiple vertebral bodies location lumbar spine are common locations for pyogenic spondylitis thoracic spine are common locations for tuberculous spondylitis intervertebral disc moderate to complete destruction in pyogenic spondylitis mild destruction or spared in tuberculous spondylitis vertebral bone seen and notably severe in tuberculous spondylitis 

20. Fungal infection Fungal infection of the spine is most commonly encountered in immunocompromised patients. These include patients with the human immunodeficiency virus (HIV), diabetes mellitus, patients on certain chemotherapeutic agents, or post transplant patients on immunosuppressive therapy. Candida and Aspergillus are MC causes Similarly to bacterial and mycobacterial infection, fungal infections may lead to diskitis/osteomyelitis. The imaging findings are similar to that of pyogenic infection.

21. Degenerative Spine Disease The prevalence of degenerative spine disease is linearly related to age. The loss of height of the intervertebral space is the earliest sign of disc degeneration on plain radiographs. Other signs, including sclerosis of the vertebral endplates, osteophytes, subchondral cyst, vacuum phenomenon and calcification, are more reliable, though they indicate late degenerative changes.

22. Vacuum phenomenon

23. Ankylosing spondylitis A seronegative spondyloarthropathy, which results in fusion (ankylosis) of the spine and sacroiliac (SI) joints, although involvement is also seen in large and small joints. SI joints- Sacroiliitis  is usually the first manifestation  and is symmetrical and bilateral the  SI joint first widen before they narrow subchondral erosions, sclerosis, and proliferation on the iliac side of the SI joints at end-stage, the SI joint may be seen as a thin line or not visible

24. Spine Early spondylitis is characterized by small erosions at the corners of vertebral bodies with reactive sclerosis: Romanus lesions of the spine (shiny corner sign) Vertebral body squaring Diffuse syndesmophytic ankylosis can give a "bamboo spine" appearance. Syndesmophytes are classically described as paravertebral ossification running parallel to the spine. Linear ossification along the central spine; representing interspinous ligament ossification can give a "dagger spine" appearance on frontal radiographs Ossification of spinal ligaments, joints and discs. Apophyseal and costovertebral arthritis and ankylosis Enthesophyte formation from enthesopathy.

25. CT scan (sagittal reformation) shows sclerotic changes and erosions of vertebral endplates Coronal CT scan of sacroiliac joints shows multiple subchondral erosions (arrows) and sclerosis (arrowheads). SHINY CORNER SIGN

26. Sagittal and coronal CT scans of thoracic and lumbar spine show syndesmophytes corresponding to osseous bridge between two adjacent vertebrae BAMBOO SPINE

27. Axial CT scan and volume reformation of sacroiliac joints show complete ankylosis with homogeneous osseous bridge passing through articulations FUSION OF SI JOINTS

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