cvj radiology by dr gaurav chauhan
TRANSCRIPT
CRANIO-VERTEBRAL JUNCTION
DR. GAURAV CHAUHANDR. R. V. PHADKE
17.11.2015
ANATOMICAL TOUR
BONES AND JOINTS
LIGAMENTSC1-OCCIPITAL OCCIPITO-C2 C1-C2
• ANTERIOR ATLANTO - OCCIPITAL MEMBRANE • APICAL LIGAMENT • ANTERIOR ATLANTO-
AXIAL LIGAMENT
• POSTERIOR ATLANTO- OCCIPITAL MEMBRANE • TECTORIAL MEMBRANE
• POSTERIOR ATLANTO-AXIAL LIGAMENT
• LATERAL ATLANTO- OCCIPITAL LIGAMENTS • ALAR LIGAMENT • TRANSVERSE
LIGAMENT
• CRUCIATE LIGAMENT
TRANSVERSE LIGAMENT APICAL LIGAMENTPOSTERIOR ATLANTO
OCCIPITALMEMBRANE
ANTTERIOR ATLANTO OCCIPITALMEMBRANE
CRUCIATE LIGAMENT
TECTORIAL MEMBRANE
EMBRYOLOGY
SCLEROTOME ORIGINS OF CVJ
RADIOGRAPHIC VIEWS
LATERAL VIEWLATERAL VIEW
• ALIGNMENT • ADI• PADI• POSTERIOR VERTEBRAL LINE• ANTERIOR VERTEBRAL LINE• SPINOLAMINAR LINE• PREVERTEBRAL SPACE• CRANIOMETRIC LINES
OBLIQUE VIEWS
OBLIQUE VIEW• VERTEBRAL FORAMINA• FACET JOINTS
OPEN MOUTH VIEWOPEN MOUTH VIEW
• ALIGNMENT OF DENS AND ATLAS • ALIGNMENT OF AXIS AND ATLAS • ATLANTO AXIAL DISTANCE• OVERHANGING ATLAS MARGINS ???• ATLANTO OCCIPITAL JOINT
AXIS ANGLE
AP VIEWAP VIEW
• ALIGNMENT OF TRANSVERSE PROCESS• ALIGNMENT OF SPINOUS PROCESS• PEDICLES• SPRENGEL’S DEFORMITY
DYNAMIC VIEWSDYNAMIC VIEWS
• FLEXION, NEUTRAL AND EXTENSION• CONTRAINDICATED IN UNSTABLE PT• ADI• PADI• SUBLUXATIONS
IMAGING MODALITIES
USG
CT SCAN
MRIMRI
• SOFT TISSUE• SPINAL CORD• BONES
CRANIOMETRY
BASILAR INVAGINATIONBASILAR IMPRESSIONPLATYBASIA
ANGLESLINES
WIDE RANGES
PAUCITY OF LITERATURE
CRANIAL SETTLING
CHAMBERLEIN LINECHAMBERLEIN LINE• SHOULD NOT PROJECT ABOVE• 3 mm PERMITTED• ABOVE 7 mm ABNORMAL
MC GREGORS LINE Mc GREGOR LINE
• DENS SHOULD NOT PROJECT ABOVE• PERMITTED LIMIT IS 6 TO 8 mm
WAKENHEIM’s LINE AND ANGLE
WAKENHEIM’s LINE AND ANGLE• LINE SHOULD FALL TANGENT TO POSTERIOR ASPECT OF TIP OF DENS• IS FALLS POST = POST CRANIOCERVICAL DISSOCIATION AND VICE VERSA• ANGLE IF LESS THAN 150, SUSPECT CORD COMPRESSION• UPTO 150 IN FLEXION, UPTO 180 IN EXTENSION
MCREE LINEMc REE LINE
• DENS SHOULD NOT PROJECT ABOVE• LOWER OCCIPITAL PROTUBERANCE LIE BELOW THIS LINE• LINE THROUGH DENS SHOULD PASS THROUGH ANT 1/3RD• NORMAL 19 to 34 mm• LESS THAN 20 mm = CORD COMPROMISE• MORE THAN 40 mm IN CHIARI
HEIGHT INDEX OF KLAUSHEIGHT INDEX OF KLAUS• < THAN 30 = BASILAR IMPRESSION• 30 to 36 mm (TENDENCY)• AVERAGE 40 – 41 mm
BOOGARD’S LINE AND ANGLE
BOOGARD’S LINE AND ANGLE
AVERAGE MAXIMUM MINIMUM122 135 119
RANAWAT LINE• 15 mm IN MALE• 13 mm IN FEMALE• IF DECREASED THEN BI• CENTRE OF C2 PEDICLE TO LINE JOINING ANT. AND POST. ARCH OF ATLAS
CLARK’S STATION• ANTERIOR ARCH SHOULD LIE IN STATION I• IF ANT ARCH LIES IN STATION II OR III, THEN BI
REDLUND JONALL CRITERIA
• MGREGOR LINE AND DISTAL MARGIN OF C2• 34 mm IN MALES AND 29 mm IN FEMALES•IF LESS THAN THAT, THEN BI
DIGASTRIC LINE
DIGASTIC LINE• LINE JOINING BILATERAL DIGASTRIC GROOVES• ATLANTO OCCIPITAL JOINT SHOULD BE 11 +/- 4 mm BELOW THIS LINE
BIMASTOID LINE
BIMASTOID LINE• LINE JOINING BILATERAL MASTOID PROCESSES• TIP OF DENS SHOULD BE LESS THAN 10 mm ABOVE THIS LINE
POWER’S RATIOPOWER’s RATIO
• < THAN 1 ALWAYS (NORMAL)• IF MORE THAN 1, SUSPECT ANT ATLANTO OCCIPITAL DISSOCIATION
BULL’S ANGLEBULL’S ANGLE
• < THAN 10° (POSTERIOR ANGLE)• ANGLE B/N 10° AND 13° (TENDENCY FOR BI )• IF ANGLE MORE THAN 13° (BI)• HARD PALATE PLANE• ATLAS PLANE
ADIATLANTO DENTAL
INTERSPACE• < THAN 5 mm IN CHILDREN• < THAN 3 mm IN ADULTS• DECREASED IN DJD• INCREASED IN DOWNs, ARTHROPATHIES, TRAUMA, GRIESEL, RA
RULE OF 12BAIBDI
BAI
BDI
BAI AND BDI• BAI UPTO 12 mm• BDI UPTO 12 mm• IF MORE THAN 12mm , SUSPECT OCCIPITI -CERVICAL DISSOCIATION
BASAL WECHLER ANGLEAVERA
GEMINIMU
MMAXIM
UM137 123 152BASAL WECHLER ANGLE
• NASION, TUBERCULUM SELLA AND BASION• IF MORE THAN 152 , PLATYBASIA• IF LESS THAN 123, KYPHOTIC SKULL• MAY OR MAY NOT BE ASSOCIATED WITH BI
POSTERIOR CERVICAL LINE
POSTERIOR CERVICAL LINE• LINE SHOULD BE CONTINOUS , SPINO LAMINAR JUNCTION JOINING• IF BREAKS, SUSPECT SUBLUXATION
ATLANTO-OCCIPITAL JOINT AXIS ANGLE
ATLANTO-OCCIPITAL JOINT AXIS ANGLE
• NORMALLY 124 to 127 DEGREE• IF MORE THAN 180 DEGREE, SEVERE OCCIPITAL CONDYLAR HYPOPLASIA
BONY ANOMALIES
ATLANTO OCCIPITAL ASSIMILATION
PARTIAL FUSION
COMPLETE FUSION
COMPLETE FUSION
PLATYBASIABASILAR INVAGINATION
PLATYBASIA
BASILAR INVAGINATION
BASILAR ARTERY COMPRESSION BOW STRING DEFORMITY
BASIOCCIPUT HYPOPLASIA
CONDYLUS TERTIUS
HYPOPLASTIC OCCIPITAL CONDYLE
FLAT ATLANTO OCCIPITAL JOINT AXIS ANGLE
POSTERIOR ATLAS DEFECTS
A
B
C
D
E
ANTERIOR ARCH OF ATLAS
SPLIT ATLAS
AXIS
ABSENT DENS
ABSENT DENS HYPOPLASTIC DENS
BERGMANN’S
OS ODONTOIDEUM
OS ODONTOIDEUM
AXISBERGMANN’S
OS ODONTOIDEUM
HYPOPLASTIC DENS
BIFID DENSI II III
CONGENITAL LESIONS OF CVJ
CHIARI 1
TONSILLAR HERNIATION
FM CROWDING
SYRINX
CHIARI 2
TONSILLAR PLUS BRAINSTEMHERNIATION
MENINGOMYELOCELE
HYDROCEPHALOUS
CHIARI 2
LEMON SIGN
BANANA SIGN
DANGLING CHOROID PLEXUS + HYDROCEPHALOUS
ANTENATAL USG
“KLIPPEL FEIL SYNDROME”
BLOCK VERTEBRAE
ATLANTO OCCIPITAL ASSIMILATION
ATLANTO OCCIPITAL ASSIMILATION
BLOCK VERTEBRAE
WASP WAIST
SCOLIOSIS
BLOCK VERTEBRAE
OPEN SPINA BIFIDA
SPRENGEL’S DEFORMITY
SPRENGEL’S DEFORMITY
SYRINX
HEMIVERTEBRA
CHIARI MALFORMATION
OMOVERTEBRAL BAR
DOWN’S SYNDROME
NORMAL
DOWN’S SYNDROME
INCREASED ADI
NARROW FORAMEN MAGNUM
AOI
AAI
BDI
BAIPADI
POWER’R RATIO
ACHONDROPLASIA
LARGE CRANIAL VAULTSMALL SKULL BASEFLAT NOSEFRONTAL BOSSING
NARROW FORAMEN MAGNUM
NARROW FORAMEN MAGNUMSMALL CISTERNA MAGNACERVICOMEDULLARY KINKHIGH UP BRAIN STEM
MUCOPOLYSACCHARIDOSIS
AAI
J SHAPED SELLA
FORAMEN MAGNUM NARROWING
DYSPLASTIC CONE SHAPED DENS
ACQUIRED LESIONS OF CVJ
RHEUMATOID
ARTHRITISDENS EROSION
DECREASED FACET JOINT SPACE PANNUS AROUND DENS
AADBONY EROSIONLATERAL TRANSLATION
DENS EROSION AADDECREASED PADI BASILAR
INVAGINATION
DENS EROSION AXIS EROSION
PSORIATIC ARTHRITIS
OSTEITIS & ENTHESITIS OF DENS
BONE FORMATION AROUND DENS & AA JOINTAAI
ACCESSORY BONE FORMATIONFUSION OF ZYGOAPOPHYSEAL JOINTS
DEGENERATIVE JOINT DISEASE
OSTEOPHYTOSIS
OSTEOPHYTOSIS
DECREASED ADI
SCLEROSIS
GOUT
DENS EROSION
CALCIFIED PSEUDOMASS
DUAL ENERGY CTCALCIUM = BLUEURATE = GREEN
SUBLUXATIONS IN AS
AAD / AAI
TRAUMATIC LESIONS
OF CVJ
OCCIPITAL CONDYLE #“ANDERSON’S”
I
II
III
ATLANTO OCCIPITAL INSTABILITY
ANTERIOR SUBLUXATION
↑ed BDI
POSTERIOR SUBLUXATION
JEFFERSON’S
OVERHANGING LATERAL MASSES OF C1TYPICAL 4 PART #
2 PART #
> THAN 7 mm
INCREASED ADI, DECREASED PADI
JEFFERSON’S FRACTURE
JEFFERSON #
STEELE’s RULE OF THIRDS
# IN ARCH OF ATLAS
ANTERIOR
POSTERIORMORE COMMON
RUPTURE OF TRANSVERSE LIGAMENT
INCREASED ADI
INCREASED ADI INJEFFERSON’S #
OVERHANGING ATLAS MARGINS
DICKMAN CLASSIFICATION
ANDERSON AND D’ALONZO CLASSIFICATIONODONTOID #
III
III
MACH EFFECT
FRACTURE ??? OPEN MOUTH VIEW
TOMOGRAMNO FRACTURE
MACH EFFECT EXPLAINED !!!
LEVINE AND EDWARD’S CLASSIFICATION
HANGMAN’S #
THE FAT “C2” SIGNFRACTURE IN BODY OF C2
VERTEBRA
LESIONS : BENIGN AND MALIGNANT
VERTEBRAL ARTERYNORMAL HYPOPLASTIC APLASTIC
FENESTRATEDMEDIAL LOOPSTRECHED LOOP SIGN
AT THE LEVEL OF ENTRY OF VERTEBRAL ARTERY IN FT OF ATLAS, MEDIAL EDGE OF FORAMEN TRANSVERSARIUM TO MIDLINE
AT THE LEVEL OF DENS TIP, SHORTEST DISTANCE OF DENS TO EITHER VERTEBRAL ARTERIES
AT THE LEVEL OF POSTERIOR ARCH OF ATLAS, MEDIAL EDGE OF VERTBRAL ARTERY TO MIDLINE
M3