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Hong JJ, Kim S, Lee GY, Chung BM. Demonstration of transverse ligament on 3D SPACE MRI in whiplash-associated disorder and nontraumatic conditions. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:1171-1178. [PMID: 38141107 DOI: 10.1007/s00586-023-08079-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 11/16/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023]
Abstract
PURPOSE This study aims to delineate the three-dimensional (3D) SPACE MRI findings of the transverse ligament (TL) in whiplash-associated disorder (WAD) patients, and to compare them with those from a nontraumatic group. METHODS A retrospective analysis was performed on cervical spine MRI scans obtained from 46 patients with WAD and 62 nontraumatic individuals. Clinical features, including the WAD grade and stage, were recorded. The TL's morphological grade and the symmetricity of the lateral atlantodental interval was assessed using axial 3D T2-SPACE images. The morphological grading was evaluated using a four-point scale: 0 = homogeneously low signal intensity with normal thickness, 1 = high signal intensity with normal thickness, 2 = reduced thickness, 3 = full-thickness rupture or indistinguishable from surrounding structures. Additionally, the number of cervical levels exhibiting degeneration was documented. RESULTS When comparing the WAD and nontraumatic groups, a significant difference was observed in the proportion of high-grade TL changes (grade 2 or 3) and the number of degenerated cervical levels. Logistic regression analysis revealed that high-grade TL changes and a lower number of degenerative levels independently predicted the presence of WAD. Within the WAD group, the subset of patients with high-grade TL changes demonstrated a significantly higher mean age than the low-grade group (grade 0 or 1). CONCLUSION High-grade morphological changes in the TL can be detected in patients with WAD through the use of 3D SPACE sequences. Clinical relevance statement 3D SPACE MRI could serve as an instrumental tool in the assessment of TL among patients with WAD. Integrating MRI findings with patient history and symptomology could facilitate the identification of potential ligament damage, and may help treatment and follow-up planning.
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Affiliation(s)
- Jung Joo Hong
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102, Heukseok-ro, Dongjak-gu, Seoul, 156-755, Republic of Korea
| | - Sujin Kim
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102, Heukseok-ro, Dongjak-gu, Seoul, 156-755, Republic of Korea
| | - Guen Young Lee
- Department of Radiology, Chung-Ang University Gwangmyeong Hospital, 110, Deokan‑ro, Gwangmyeong‑si, Gyeonggi‑do, Republic of Korea
| | - Bo Mi Chung
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102, Heukseok-ro, Dongjak-gu, Seoul, 156-755, Republic of Korea.
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Craniocervical Junction and Cervical Spine Anatomy. Neuroimaging Clin N Am 2022; 32:875-888. [DOI: 10.1016/j.nic.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Izzo R, Popolizio T, Balzano RF, Simeone A, Gasparotti R, Scarabino T, Muto M. Imaging of cranio-cervical junction traumas. Eur J Radiol 2020; 127:108960. [PMID: 32298957 DOI: 10.1016/j.ejrad.2020.108960] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/14/2020] [Indexed: 11/19/2022]
Abstract
The craniocervical junction (CCJ) or upper cervical spine (UCS) has anatomic features and a biomechanics completely different from the other spinal segment of the spine. Several ligaments and muscles control its motion and function and ensure the maximum mobility and the visual and auditory spatial exploration. UCS traumas represent approximately one-third of all cervical spine injuries. Most of UCS traumas results from blows to the head and sudden deceleration of the body. Thanks to the improvement of the Advanced Trauma Life Support protocols dissociative injuries of CCJ have become less lethal onsite. In other less severe but unstable injuries, patients are neurologically intact at presentation, but they may deteriorate during the stay in hospital, with important clinical and medico-legal consequences. Knowing the peculiarities of UCS is fundamental for the early detection of imaging findings that influences the patient management and outcome. The classification of UCS traumas is mechanistic. More than in any other spinal segment, fractures of CCJ bones can occur without generating instability; on the contrary highly unstable injuries may not be associated with bone fractures. An early and correct diagnosis of occipito-cervical instability may prevent secondary neurological injury. The goal of imaging is to identify which patients can benefit of surgical stabilization and prevent secondary neurologic damage. Actual helical multidetector-CT (MDCT) offers high sensitivity and specificity for bone lesions and displacements in cervical spine traumas, but magnetic resonance imaging (MRI) is increasingly being used to evaluate soft tissues and ligaments, and mainly to identify possible spinal cord injury.
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Affiliation(s)
- Roberto Izzo
- Radiology Department, Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy.
| | - Teresa Popolizio
- Radiology Department, Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy.
| | | | - Anna Simeone
- Radiology Department, Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | | | | | - Mario Muto
- Neuroradiology Department, A. Cardarelli Hospital, Napoli, Italy
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Unal TC, Dolas I, Unal OF. Unilateral Alar Ligament Injury: Diagnostic, Clinical, and Biomechanical Features. World Neurosurg 2019; 132:e878-e884. [DOI: 10.1016/j.wneu.2019.07.198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/25/2019] [Accepted: 07/26/2019] [Indexed: 10/26/2022]
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Beckmann NM, West OC, Nunez D, Kirsch CF, Aulino JM, Broder JS, Cassidy RC, Czuczman GJ, Demertzis JL, Johnson MM, Motamedi K, Reitman C, Shah LM, Than K, Ying-Kou Yung E, Beaman FD, Kransdorf MJ, Bykowski J. ACR Appropriateness Criteria® Suspected Spine Trauma. J Am Coll Radiol 2019; 16:S264-S285. [DOI: 10.1016/j.jacr.2019.02.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 02/07/2019] [Indexed: 02/05/2023]
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Santin MDN, Cebula H, Ollivier I, Todeschi J, Baloglu S, Proust F. Diagnosis and suggested treatment against an isolated unilateral rupture of the alar ligament - Concerning one case. Neurochirurgie 2017; 63:478-482. [PMID: 29122308 DOI: 10.1016/j.neuchi.2017.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 07/10/2017] [Accepted: 07/28/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND An isolated rupture of the alar ligament is a rare occurrence with only a few cases reported in the literature. CASE REPORT The objective was to report the case of a young man with a unilateral rupture of the alar ligament that we closely monitored, clinically and radiologically, in order to describe the evolution of the alar ligament lesions. CONCLUSION Radiological diagnosis using cervical MRI and duration of the conservative treatment remain debated and we proposed a close radiological follow-up in order to best understand the nature of these ligament lesions and their evolution following specific treatment.
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Affiliation(s)
- M-D-N Santin
- Service de Neurochirurgie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France.
| | - H Cebula
- Service de Neurochirurgie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France
| | - I Ollivier
- Service de Neurochirurgie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France
| | - J Todeschi
- Service de Neurochirurgie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France
| | - S Baloglu
- Service de Neuroradiologie (Radiologie 2), hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France
| | - F Proust
- Service de Neurochirurgie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France
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Abstract
The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to neck pain. J Orthop Sports Phys Ther. 2017;47(7):A1-A83. doi:10.2519/jospt.2017.0302.
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The craniocervical junction: embryology, anatomy, biomechanics and imaging in blunt trauma. Insights Imaging 2016; 8:29-47. [PMID: 27815845 PMCID: PMC5265194 DOI: 10.1007/s13244-016-0530-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 10/09/2016] [Accepted: 10/13/2016] [Indexed: 12/15/2022] Open
Abstract
Imaging of the blunt traumatic injuries to the craniocervical junction can be challenging but central to improving morbidity and mortality related to such injury. The radiologist has a significant part to play in the appropriate management of patients who have suffered injury to this vital junction between the cranium and the spine. Knowledge of the embryology and normal anatomy as well as normal variant appearances avoids inappropriate investigations in these trauma patients. Osseous injury can be subtle while representing important radiological red flags for significant underlying ligamentous injury. An understanding of bony and ligamentous injury patterns can also give some idea of the biomechanics and degree of force required to inflict such trauma. This will assist greatly in predicting risk for other critical injuries related to vital neighbouring structures such as vasculature, brain stem, cranial nerves and spinal cord. The embryology and anatomy of the craniocervical junction will be outlined in this review and the relevant osseous and ligamentous injuries which can arise as a result of blunt trauma to this site described together. Appropriate secondary radiological imaging considerations related to potential complications of such trauma will also be discussed. TEACHING POINTS • The craniocervical junction is a distinct osseo-ligamentous entity with specific functional demands. • Understanding the embryology of the craniocervical junction may prevent erroneous radiological interpretation. • In blunt trauma, the anatomical biomechanical demands of the ligaments warrant consideration. • Dedicated MRI sequences can provide accurate evaluation of ligamentous integrity and injury. • Injury of the craniocervical junction carries risk of blunt traumatic cerebrovascular injury.
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Wenz H, Kerl HU, Maros ME, Wenz R, Kalvin K, Groden C, Nölte I. Signal changes of the alar ligament in a healthy population: a dispositional or degenerative consequence? J Neurosurg Spine 2015; 23:544-550. [PMID: 26186638 DOI: 10.3171/2015.1.spine141214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECT The alar ligaments (ALs) are vital for stabilizing the craniocervical junction. In terms of morphology, their appearance varies and is visible on MRI. Dark signal of the AL on proton-density (PD)-weighted images is generally considered the norm, but the etiology of frequently observed signal hyperintensities is poorly understood. Using spectral fat suppression, signal hyperintensities can be differentiated into fat- and nonfat-related hyperintensities (NFH). Although signal hyperintensities have no evident association with whiplash-associated disorder, age-related degeneration has often been theorized. Therefore, this study investigates the signal intensities of the ALs on 3.0-T MRI with special reference to age. Expanding thereon, the authors investigated the relationship between signal hyperintensities and patient characteristics, such as height, weight, and sex. METHODS Sixty-six healthy volunteers were scanned using 3.0-T PD-weighted MRI, including spectral fat suppression of the craniocervical junction. The study population was separated into 2 groups (old vs young) using 2 approaches: dichotomization at the median age (40.0 years) and the calculated threshold (28.5 years) using receiver operating characteristics (ROC). The AL was independently characterized with respect to continuity, course, shape, signal intensity, and graduation of homogeneity by 2 experienced neuroradiologists. Signal intensity was differentiated into fat-related hyperintensity and NFH. Univariate and multivariate logistic regression models were employed to investigate the relationship between patient characteristics and signal intensities. RESULTS Two different AL patterns were observed: inhomogeneous (33.3%) and homogeneous (66.7%). The latter pattern was mostly surrounded by a small dark rim (56.8%). Fat could be identified in 15.9% of all ALs (21 of 132 patients), and NFH was identified in 17.4% of all ALs (23 of 132 patients). Here, 28.5 years was the preferred threshold, demonstrating a relatively high sensitivity for dichotomizing the population based on the ROC of NFH. The most relevant factor for having NFH was being older than the calculated threshold (odds ratio [OR] 3.420, p = 0.051). Fat-related hyperintensities occurred significantly more frequently in men than women (OR 0.110 and p = 0.007 for women; OR 9.075 and p = 0.007 for men). Height was the second most significant factor: for every 1-cm increase, the odds of having fat lesions increased by approximately 10% (OR 1.102; p = 0.017). CONCLUSIONS This study shows that AL signal hyperintensities are substantially influenced by age, sex, and height in healthy individuals. Regarding fat-related hyperintensities, the most relevant factors proved to be sex and height. The odds of detecting NFH increased almost significantly after a relatively young age (> 28.5 years) and were remarkably more frequent in individuals older than 28.5 years. The authors caution presumptions equating signal alterations with age-related deterioration. Instead, they suggest that dispositional factors such as sex and height are more relevant in the AL constitution. Signal alterations in ALs naturally occur in healthy symptom-free individuals, underscoring the importance of cautiously interpreting such lesions on posttraumatic MRI scans.
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Affiliation(s)
- Holger Wenz
- Department of Neuroradiology, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Hans Ulrich Kerl
- Department of Neuroradiology, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Mate Elod Maros
- Department of Neuroradiology, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ralf Wenz
- Department of Neuroradiology, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Kira Kalvin
- Department of Neuroradiology, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Christoph Groden
- Department of Neuroradiology, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ingo Nölte
- Department of Neuroradiology, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
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Worsfold C. When range of motion is not enough: Towards an evidence-based approach to medico-legal reporting in whiplash injury. J Forensic Leg Med 2014; 25:95-9. [DOI: 10.1016/j.jflm.2014.04.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 03/05/2014] [Accepted: 04/15/2014] [Indexed: 10/25/2022]
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Clinical management of cranio-vertebral instability after whiplash, when guidelines should be adapted: a case report. ACTA ACUST UNITED AC 2014; 19:618-21. [PMID: 24560490 DOI: 10.1016/j.math.2014.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Revised: 01/24/2014] [Accepted: 01/26/2014] [Indexed: 11/20/2022]
Abstract
Cranio-vertebral instability (CVI) due to loss of bony or ligamentous integrity is one of the sequelae that may result after a whiplash mechanism injury. Due to the lack of specificity of diagnostic tests, this condition is often missed and the default classification of whiplash associated disorder (WAD) is assigned. This case report describes a 14-year-old boy who was initially classified with WAD II after a rugby injury. He was initially advised to return to usual activity, a treatment recommended in clinical guidelines for WAD. Due to an adverse response to this course of action, his primary carer, a musculoskeletal physiotherapist, continued with facilitating secondary referrals that ultimately led to a specialist physiotherapist. The patient was subsequently found to have CVI arising from a loss of bony integrity due to spina bifida atlanto, a congenital defect in the atlas. Treatment thus was immobilization and stabilization, a treatment usually recommended against in WAD guidelines. The patient recovered and within 8 weeks had returned to school and non-contact sports. This case study, therefore, presents a scenario where current clinical guidelines for whiplash could not be followed, and where pursuing clinical reasoning led to accurate diagnosis as well as safe and tailored management. The case also highlights the integrated roles that primary and specialist health professionals should play in the clinical pathway of care after WAD. As a result, an expanded diagnostic algorithm and pathway of care for WAD are proposed.
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Tegler G, Sörensen J, Ericson K, Björck M, Wanhainen A. 4D-PET/CT with [11C]-PK11195 and [11C]-d-deprenyl Does not Identify the Chronic Inflammation in Asymptomatic Abdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2013; 45:351-6. [DOI: 10.1016/j.ejvs.2013.01.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 01/08/2013] [Indexed: 11/27/2022]
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Espeland A, Vetti N, Kråkenes J. Are two readers more reliable than one? A study of upper neck ligament scoring on magnetic resonance images. BMC Med Imaging 2013; 13:4. [PMID: 23327567 PMCID: PMC3626747 DOI: 10.1186/1471-2342-13-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 01/16/2013] [Indexed: 02/06/2023] Open
Abstract
Background Magnetic resonance imaging (MRI) studies typically employ either a single expert or multiple readers in collaboration to evaluate (read) the image results. However, no study has examined whether evaluations from multiple readers provide more reliable results than a single reader. We examined whether consistency in image interpretation by a single expert might be equal to the consistency of combined readings, defined as independent interpretations by two readers, where cases of disagreement were reconciled by consensus. Methods One expert neuroradiologist and one trained radiology resident independently evaluated 102 MRIs of the upper neck. The signal intensities of the alar and transverse ligaments were scored 0, 1, 2, or 3. Disagreements were resolved by consensus. They repeated the grading process after 3–8 months (second evaluation). We used kappa statistics and intraclass correlation coefficients (ICCs) to assess agreement between the initial and second evaluations for each radiologist and for combined determinations. Disagreements on score prevalence were evaluated with McNemar’s test. Results Higher consistency between the initial and second evaluations was obtained with the combined readings than with individual readings for signal intensity scores of ligaments on both the right and left sides of the spine. The weighted kappa ranges were 0.65-0.71 vs. 0.48-0.62 for combined vs. individual scoring, respectively. The combined scores also showed better agreement between evaluations than individual scores for the presence of grade 2–3 signal intensities on any side in a given subject (unweighted kappa 0.69-0.74 vs. 0.52-0.63, respectively). Disagreement between the initial and second evaluations on the prevalence of grades 2–3 was less marked for combined scores than for individual scores (P ≥ 0.039 vs. P ≤ 0.004, respectively). ICCs indicated a more reliable sum score per patient for combined scores (0.74) and both readers’ average scores (0.78) than for individual scores (0.55-0.69). Conclusions This study was the first to provide empirical support for the principle that an additional reader can improve the reproducibility of MRI interpretations compared to one expert alone. Furthermore, even a moderately experienced second reader improved the reliability compared to a single expert reader. The implications of this for clinical work require further study.
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Affiliation(s)
- Ansgar Espeland
- Department of Radiology, Haukeland University Hospital, Jonas Liesvei 65, 5021, Bergen, Norway.
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Li Q, Shen H, Li M. Magnetic resonance imaging signal changes of alar and transverse ligaments not correlated with whiplash-associated disorders: a meta-analysis of case-control studies. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2012; 22:14-20. [PMID: 23143091 DOI: 10.1007/s00586-012-2490-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 08/11/2012] [Accepted: 08/18/2012] [Indexed: 12/29/2022]
Abstract
PURPOSE Hypothesis that loss of integrity of the membranes in the craniocervical junction might be the cause of neck pain in patients with whiplash-associated disorders (WADs) has been proposed. In recent years, with development of more detailed magnetic resonance imaging (MRI) techniques, morphologic changes of the ligaments and membranes in the craniocervical junction, especially alar and transverse ligaments have been discussed. A meta-analysis was performed to evaluate the relationship of MRI signal changes of alar and transverse ligaments and WADs. METHODS A systematic search of EMBASE, PUBMED, and Cochrane Library and references from eligible articles were conducted. Comparative studies reporting on evaluating the relationship between MRI high-signal changes of alar and transverse ligaments and WADs were regarded eligible. A pooled estimate of effect size was produced. RESULTS Alar ligaments: Six studies (total n = 622) were included. MRI signal changes of alar ligaments did not appear to be related with WADs (P = 0.20, OR = 1.54, 95 % CI = 0.80-2.94). Heterogeneity was present (I (2) = 46 %, P = 0.10), which was eliminated upon sensitivity analysis bringing the OR to 1.27 (95 % CI = 0.87-1.86, I (2) = 0 %). Transverse ligaments: Four studies (total n = 489) were included. MRI signal changes of transverse ligament did not appear to be related with WADs (P = 0.51, OR = 1.44, 95 % CI = 0.49-4.21). Heterogeneity was present (I (2) = 77 %, P = 0.005), which was eliminated upon sensitivity analysis bringing the OR to 0.79 (95 % CI = 0.49-1.28, I (2) = 0 %). CONCLUSION MRI signal changes of alar and transverse ligaments are not supposed to be caused by whiplash injury, and MRI examination of alar and transverse ligaments should not be used as the routine workup of patients with WADs.
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Affiliation(s)
- Quan Li
- Department of Orthopedics, Changhai Hospital, 168 Changhai Road, Yangpu District, Shanghai 200433, China.
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Schmidt P, Mayer TE, Drescher R. Delineation of alar ligament morphology: comparison of magnetic resonance imaging at 1.5 and 3 Tesla. Orthopedics 2012; 35:e1635-9. [PMID: 23127456 DOI: 10.3928/01477447-20121023-22] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Rupture of the alar and transverse ligaments due to whiplash injury can lead to upper cervical spine instability and subsequent neurological deterioration. The purpose of this study was to evaluate the normal anatomical variability of the alar ligaments in asymptomatic individuals with 3-T magnetic resonance imaging (MRI) and to compare the findings with standard 1.5-T examinations. Thirty-six participants underwent 3-T and 1.5-T MRIs. Magnetic resonance imaging findings were analyzed by classifying the alar ligaments with regard to the features detectability, signal intensity compared with muscle tissue, homogeneity, shape, spatial orientation, and symmetry. Delineation of the alar ligaments was significantly better on 3-T images, which were subjectively preferred for evaluation. The alar ligaments showed great variability. In the majority of participants, the alar ligaments were hypointense to muscle tissue, inhomogeneous, and different in shape and orientation. A statistically significantly higher number of ligaments appeared symmetric on 3-T imaging, indicating that 1.5-T imaging may underestimate the proportion of patients with normal, symmetric ligaments. This study demonstrates that high-field 3-T MRI provides better visualization of the alar ligaments compared with 1.5-T MRI. The higher signal-to-noise ratio allows detection of small signal changes. A great interindividual variety of the MRI morphology of the alar ligaments was found in participants with no history of neck trauma. Further studies with more participants are necessary to evaluate alar ligament pathologies in patients with a history of whiplash injury.
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Affiliation(s)
- Peter Schmidt
- Department of Neuroradiology, Institute of Radiology, University Hospital Jena, Jena, Germany.
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Hefny MA, Ghaly MS, Greish SM, Abogresha NM, Fahim AE. Spinal accessory neuropathy in patients with chronic neck pain. World J Rheumatol 2012; 2:21-26. [DOI: 10.5499/wjr.v2.i2.21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the presence of spinal accessory neuropathy in patients with chronic neck pain.
METHODS: Patients with pain either regional or focal in the neck or shoulders for at least 6 mo (chronic neck pain) were recruited randomly from the Rheumatology and Rehabilitation Outpatient Clinic at the Faculty of Medicine-Suez Canal University. Two groups were compared: 30 patients with chronic neck pain with mean age (36.97 ± 12.45 years) and 10 apparently healthy controls. Trapezius muscle examination including inspection and range of motion both active and passive was performed. A full clinical neurological examination was carried out to exclude peripheral neuropathy and motor neuron disease. According to the subject’s type of work, cases were categorized into labor-intensive and non-labor intensive tasks. A nerve conduction study (NCS) was performed on spinal accessory nerves at both sides for all patients and controls. Parameters including latencies and amplitudes of compound motor action potential (CMAP) were compared with the chronicity of neck pain using the neck disability score. This cross sectional study was carried in the Rheumatology and Rehabilitation Department, at Suez Canal University Hospital, Ismailia, Egypt.
RESULTS: Physical examination revealed that 80% of cases had spinal trapezius muscle spasm. Restricted neck motion was present in 16.6% of cases. No one suffered from muscle wasting or weakness. Pain was bilateral in 18 patients (60%), localized to the right side in six patients (20%) and localized to the left side in six patients (20%). The causes of neck pain in the patients studied were nonspecific, due to physical stresses, cervical spondylosis and mild cervical disc herniation. Mean disease duration in patients with labor-intensive tasks was (3.9 ± 2.1 years), which was longer than that in patients with non-labor intensive tasks (3.1 ± 1.9 years); however, this difference was statistically insignificant. Spinal accessory NCSs were performed while subjects were in sitting positions and relaxed with naturally suspended arms to minimize muscular movement. The results of electrophysiological studies revealed that mean right and left latencies of the spinal accessory nerve were 2.96 ± 0.69 ms, 2.98 ± 0.61 ms in the patient group and 2.44 ± 0.38 ms, 2.33 ± 0.36 ms in control group respectively. These differences were statistically significant with P = 0.028 and 0.006 respectively. Spinal accessory NCS showed normal CMAP amplitude in both patients and controls. Comparing the results of the neck disability index (NDI) to different characteristics in patients with chronic neck pain, showed that patients with labor-intensive work had a higher NDI score mean (34.7 ± 9.5) compared to those with non-labor-intensive work, with significant statistical difference (P = 0.011). In addition, mean NDI scores were higher in males, and patients aged over 40 years and this difference was statistically significant (P = 0.007 and P = 0.009 respectively). Correlation studies between right and left spinal accessory nerve latencies and disability percent calculated using the NDI revealed a positive correlation. Moreover, there was a positive correlation between age and disability percent.
CONCLUSION: This study demonstrates electrophysiological evidence of demyelination in a significant proportion of patients with chronic cervical pain.
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Effect of magnetic resonance imaging field strength on delineation and signal intensity of alar ligaments in healthy volunteers. Spine (Phila Pa 1976) 2012; 37:E1062-7. [PMID: 22498994 DOI: 10.1097/brs.0b013e31825831ca] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective study of healthy volunteers. OBJECTIVE To evaluate the influence of magnetic resonance imaging (MRI) field strength on the delineation and signal intensity of alar ligaments (AL) in healthy volunteers. SUMMARY OF BACKGROUND DATA The fact that AL physiologically show morphologic variabilities is well established. However, presence and etiology of high-signal intensities within the AL as well as the influence of the MRI field strength on the signal characteristics of AL are still not completely understood. METHODS.: Coronal and sagittal 2-mm proton-density weighted sequences were acquired in 50 healthy volunteers using different MRI field strengths (1 T, 1.5 T, 3 T). Delineation and signal characteristics of AL were evaluated by 2 neuroradiologists independently. Differences concerning delineation and signal intensity between the MRI scanners, inter rater reliability between the 2 readers, and intrarater reliability at different time points were calculated. RESULTS Delineation of AL was significantly better both on 3 T and 1.5 T than on 1 T (P = 0.05) in sagittal as well as in coronal view. In coronal view delineation was significantly better on 3 T than on 1.5 T, whereas in sagittal view no significant difference was evident when comparing 1.5 T and 3 T. Concerning signal intensity of AL in sagittal view, there was no significant difference between the 3 different field strengths. Inter-rater and intrarater agreements were fair to moderate with respect to delineation as well as signal intensity of AL. CONCLUSION 1.5 T and 3 T significantly improve the delineation of AL when compared with lower field strength (1 T), but signal intensity of the AL in healthy volunteers is not influenced by the field strength. Increased signal is present in asymptomatic subjects on both low- and high-field magnetic resonance systems. Accordingly, the pathologic relevance of increased signal intensity of the AL, regardless of field strength, may not be indicative of traumatic AL injury.
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Vetti N, Kråkenes J, Ask T, Erdal KA, Torkildsen MDN, Rørvik J, Gilhus NE, Espeland A. Follow-up MR imaging of the alar and transverse ligaments after whiplash injury: a prospective controlled study. AJNR Am J Neuroradiol 2011; 32:1836-41. [PMID: 21920865 DOI: 10.3174/ajnr.a2636] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The cause and clinical relevance of upper neck ligament high signal intensity on MR imaging in WAD are controversial. The purpose of this study was to explore changes in the signal intensity of the alar and transverse ligaments during the first year after a whiplash injury. MATERIALS AND METHODS Dedicated high-resolution upper neck proton attenuation-weighted MR imaging was performed on 91 patients from an inception WAD1-2 cohort, both in the acute phase and 12 months after whiplash injury, and on 52 controls (noninjured patients with chronic neck pain). Two blinded radiologists independently graded alar and transverse ligament high signal intensity 0-3, compared initial and follow-up images to assess alterations in grading, and solved any disagreement in consensus. The Fisher exact test was used to compare proportions. RESULTS Alar and transverse ligament grading was unchanged from the initial to the follow-up images. The only exceptions were 1 alar ligament changing from 0 to 1 and 1 ligament from 1 to 0. The prevalence of grades 2-3 high signal intensity in WAD was thus identical in the acute phase and after 12 months, and it did not differ from the prevalence in noninjured neck pain controls (alar ligaments 33.0% versus 46.2%, P = .151; transverse ligament 24.2% versus 23.1%, P = 1.000). CONCLUSIONS Alar and transverse ligament high signal intensity in patients with WAD1-2 observed within the first year after injury cannot be explained by the trauma. Dedicated upper neck MR imaging cannot be recommended as a routine examination in these patients.
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Affiliation(s)
- N Vetti
- Department of Radiology, Haukeland University Hospital, Bergen, Norway.
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Abstract
STUDY DESIGN Resident's case problem. BACKGROUND Patients often present to physical therapists with chief complaints of neck pain, occipital headache, and dizziness associated with a past history of cervical spine injury. These symptoms may be associated with various cervical spine conditions, including craniocervical junction (CCJ) hypermobility. DIAGNOSIS This report reviews the history, physical exam, and diagnostic imaging findings of a patient with the above symptoms. This patient, who had a history of multiple cervical spine injuries, was examined with 2 manual therapy provocative tests: the Sharp-Purser test, which is intended to stress the transverse ligament and odontoid, and the modified lateral shear test, which is intended to stress the alar ligaments. The lateral shear test was perceived as demonstrating excessive mobility and a soft end feel, with a "shift" of C1 on C2. Stress cervical radiographs, obtained using open-mouth projections in neutral, left, and right cervical lateral flexion, revealed a 3-mm lateral offset of the right lateral mass of C1 on C2. MRI evaluation of the lower cervical spine did not reveal any significant disc derangement; however, images of the soft tissues of the craniocervical junction were not obtained. Based on the examination and imaging studies, the patient was determined to have a previously undiagnosed hypermobility of the atlantoaxial joint. DISCUSSION The patient was advised to avoid rotational manipulation and end range lateral flexion stretching exercises. Axial traction manipulation techniques, midrange stabilization exercises, and postural advice appeared to provide good relief of symptoms. Physical therapists should consider the possibility of CCJ hypermobility in the frontal plane when examining the cervical spine in patients with chronic neck pain, headache, and a past history of trauma. The lateral shear test and stress radiography may provide simple screening tests for occult CCJ hypermobility; however, the reliability and validity of these tests is lacking. Further research on diagnosis and management of CCJ hypermobility is warranted. LEVEL OF EVIDENCE Differential diagnosis, level 4.
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Magnetic resonance imaging of the alar and transverse ligaments in acute whiplash-associated disorders 1 and 2: a cross-sectional controlled study. Spine (Phila Pa 1976) 2011; 36:E434-40. [PMID: 21178847 DOI: 10.1097/brs.0b013e3181da21a9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cross-sectional. OBJECTIVE To describe alar- and transverse-ligament magnetic resonance imaging (MRI) high-signal changes in acute whiplash-associated disorders (WAD) grades 1 and 2 in relation to the severity and mechanics of trauma, and to compare them with controls. SUMMARY OF BACKGROUND DATA The alar and transverse ligaments are important stabilizers at the craniovertebral junction. Acute injury of these ligaments should be detected as high-signal changes on high-resolution MRI. METHODS In the study, 114 consecutive acute WAD 1-2 patients and 157 noninjured controls underwent upper-neck high-resolution MRI, using proton-weighted sequences and Short Tau Inversion Recovery (STIR). Two blinded radiologists independently graded high-signal changes 0 to 3 on proton images and assessed ligament high-signal intensity on STIR. Image quality was evaluated as good, reduced, or poor (not interpretable). Multiple logistic regression was used for both within- and between-groups analyses. RESULTS All proton and STIR images were interpretable. Interobserver agreement for grades 2 to 3 versus grades 0 to 1 changes was moderate to good (κ = 0.71 alar; and 0.54 transverse). MRI showed grades 2 to 3 alar ligament changes in 40 (35.1%) and grades 2 to 3 transverse ligament changes in 27 (23.7%) of the patients. Such changes were related to contemporary head injury (P = 0.041 alar), neck pain (P = 0.042 transverse), and sex (P = 0.033 transverse) but did not differ between patients and controls (P = 0.433 alar; and 0.254 transverse). STIR ligament signal intensity, higher than bone marrow, was found in only three patients and one control. CONCLUSION This first study on high-resolution MRI of craniovertebral ligaments in acute WAD 1-2 indicates that such trauma does not induce high-signal changes. Follow-up studies are needed to find out whether pretraumatic high-signal changes imply reduced ligament strength and can predict chronic WAD.
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Tubbs RS, Hallock JD, Radcliff V, Naftel RP, Mortazavi M, Shoja MM, Loukas M, Cohen-Gadol AA. Ligaments of the craniocervical junction. J Neurosurg Spine 2011; 14:697-709. [PMID: 21395398 DOI: 10.3171/2011.1.spine10612] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The specialized ligaments of the craniocervical junction must allow for stability yet functional movement. Because injury to these important structures usually results in death or morbidity, the neurosurgeon should possess a thorough understanding of the anatomy and function of these ligaments. To the authors' knowledge, a comprehensive review of these structures is not available in the medical literature. The aim of the current study was to distill the available literature on each of these structures into one offering.
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Affiliation(s)
- R Shane Tubbs
- Section of Pediatric Neurosurgery, Children's Hospital, Birmingham, Alabama 35233, USA.
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Lummel N, Zeif C, Kloetzer A, Linn J, Brückmann H, Bitterling H. Variability of morphology and signal intensity of alar ligaments in healthy volunteers using MR imaging. AJNR Am J Neuroradiol 2011; 32:125-30. [PMID: 20864518 DOI: 10.3174/ajnr.a2255] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Evaluation of alar traumatic injuries by using MR imaging is frequently performed. This study investigates the variability of morphology and signal intensity of alar ligaments in healthy volunteers so that pathology can be more accurately defined. MATERIALS AND METHODS Fifty healthy volunteers were examined on a 1.5T MR imaging scanner with 2-mm PD-weighted sequences in 3 planes. Delineation of the alar ligaments in 3 planes and signal-intensity characteristics on sagittal planes were analyzed by using a 4-point grading scale. Variability of courses and morphologic characteristics were described. RESULTS Delineation of alar ligaments was best viewed in the coronal plane, followed by the sagittal and axial planes. In the sagittal view, 6.5% of alar ligaments appeared homogeneously dark. Hyperintense signal intensity in up to one-third of the cross-sectional area was present in 33% of cases; in up to two-thirds of the cross-sectional area, in 45% of cases; and in more than two-thirds of the cross-sectional area, in 15% of cases. Of alar ligaments, 58.5% ascended laterally, 40.5% ran horizontally, and 1% descended laterally. The cross-sectional area was round in 41.5%, oval in 51.5%, and winglike in 6.5%. CONCLUSIONS On 1.5T MR imaging, the alar ligaments can be delineated best in the coronal and sagittal planes. Our data indicate a remarkable variability of morphology and course as well as signal intensity. This finding is contradictory to former publications assigning such alterations exclusively to patients with trauma.
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Affiliation(s)
- N Lummel
- Department of Neuroradiology, University of Munich, Munich, Germany.
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Vetti N, Kråkenes J, Eide GE, Rørvik J, Gilhus NE, Espeland A. Are MRI high-signal changes of alar and transverse ligaments in acute whiplash injury related to outcome? BMC Musculoskelet Disord 2010; 11:260. [PMID: 21070654 PMCID: PMC2989946 DOI: 10.1186/1471-2474-11-260] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Accepted: 11/11/2010] [Indexed: 11/16/2022] Open
Abstract
Background Upper neck ligament high-signal changes on magnetic resonance imaging (MRI) have been found in patients with whiplash-associated disorders (WAD) but also in non-injured controls. The clinical relevance of such changes is controversial. Their prognostic role has never been evaluated. The purpose of this study was to examine if alar and transverse ligament high-signal changes on MRI immediately following the car accident are related to outcome after 12 months for patients with acute WAD grades 1-2. Methods Within 13 days after a car accident, 114 consecutive acute WAD1-2 patients without prior neck injury or prior neck problems underwent upper neck high-resolution proton-weighted MRI. High-signal changes of the alar and transverse ligaments were graded 0-3. A questionnaire including the impact of event scale for measuring posttraumatic stress response and questions on patients' expectations of recovery provided clinical data at injury. At 12 months follow-up, 111 (97.4%) patients completed the Neck Disability Index (NDI) and an 11-point numeric rating scale (NRS-11) on last week neck pain intensity. Factors potentially related to these outcomes were assessed using multiple logistic regression analyses. Results Among the 111 responders (median age 29.8 years; 63 women), 38 (34.2%) had grades 2-3 alar ligament changes and 25 (22.5%) had grades 2-3 transverse ligament changes at injury. At 12 months follow-up, 49 (44.1%) reported disability (NDI > 8) and 23 (20.7%) neck pain (NRS-11 > 4). Grades 2-3 ligament changes in the acute phase were not related to disability or neck pain at 12 months. More severe posttraumatic stress response increased the odds for disability (odds ratio 1.46 per 10 points on the impact of event scale, p = 0.007) and so did low expectations of recovery (odds ratio 4.66, p = 0.005). Conclusions High-signal changes of the alar and transverse ligaments close after injury did not affect outcome for acute WAD1-2 patients without previous neck problems. High-resolution upper neck MRI has limited value for the initial examination and follow-up of such patients.
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Affiliation(s)
- Nils Vetti
- Department of Radiology, Haukeland University Hospital, Bergen, Norway.
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Thomann KD, Schomerus C, Sebestény T, Rauschmann M. ["Isolated injury" of the alar ligaments: MRI diagnosis and surgical therapy]. DER ORTHOPADE 2010; 39:285-98. [PMID: 20177876 DOI: 10.1007/s00132-009-1546-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
UNLABELLED Spinal distortions caused by traffic collisions play a large role in medical expert opinions. Prolonged or chronic conditions present particular difficulties. The radiologist E. Volle developed and published a system for the classification of isolated injuries of the alar ligaments. As a result, surgery on the craniocervical junction was carried out in a large number of patients and the results published on multiple occasions. This article describes the anatomy of the alar ligaments, complicated injuries, the concept of the isolated lesion of the alar ligaments and their surgical management. German and international publications are evaluated. RESULT It was impossible to substantiate isolated injuries to alar ligaments. According to current knowledge, the published results are based on a misinterpretation of MRI findings. These results are to be considered as artefacts. There is no anatomical correlation for the classification of isolated injuries to alar ligaments. Surgical stabilisation due to an allegedly isolated injury to the alar ligaments is therefore not indicated. This statement does not apply to injuries sustained in high-speed trauma in combination with complex injuries of the atlanto-occipital and atlanto-dental-joint (joint capsules, atlanto-occipital membrane) with clear signs of instability.
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Affiliation(s)
- K-D Thomann
- Institut für Versicherungsmedizin, Eschersheimer Landstr. 353, 60320, Frankfurt/Main, Deutschland.
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Vetti N, Alsing R, Kråkenes J, Rørvik J, Gilhus NE, Brun JG, Espeland A. MRI of the transverse and alar ligaments in rheumatoid arthritis: feasibility and relations to atlantoaxial subluxation and disease activity. Neuroradiology 2010; 52:215-23. [DOI: 10.1007/s00234-009-0650-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Accepted: 12/10/2009] [Indexed: 11/24/2022]
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