Malformed vertebrae: a clinical and imaging review

Monosymmetros Cephalothoracopagus Tetrabrachius and Tetrapus Piglets with Syndromic Evolution

Conjoined twins are rare congenital malformations that have been reported in mammals. Two different cases are presented in this study. Case No. 1 features monocephalic, thoracopagus-conjoined twin piglets with anencephaly and palatoschisis of the Pietrain breed, and case No. 2 features monocephalic, thoracopagus conjoined twin piglets with palatoschisis and bifid root tongue of a mixed breed. These cases were examined using post-mortem and computed tomography (CT) examinations. In both cases, the conjoined symmetrical twins had a single head, one neck, and fused thoracic cavities, while the abdominal cavities were separated. Similarly, in both cases, they had four forelimbs and four hindlimbs and duplicated foramen magnum. During CT examination, in case No. 1, severe abnormalities were observed in the skull and vertebral column. In the left twin, occult dysraphism was seen from the C2 vertebra until the end of the vertebral column, and in the right twin, from the C3 vertebra until the end of the state vertebral level. In case No. 2, the oral cavity contained a tongue with a bifid root connected with one hyoid bone, and the soft palate presented a small cleft. During CT examination, the parietal bone and the occipital bones were partially duplicated. This case also presented occult dysraphism, but only in the cervical vertebrae, C1-C6 for the left twin and C1-C5 for the right twin. In both cases, abnormalities of the internal organs were revealed during necropsy. Conjoined twins with multiple congenital anomalies presented here enhance our understanding of the various clinical forms of conjoined cases in veterinary medicine.

Total spine MRI for the preoperative evaluation of adolescent idiopathic scoliosis: Part 2 - spinal cord tumors, dysraphisms, diastematomyelia, and vertebral anomalies

Adolescent idiopathic scoliosis is a commonly encountered condition often diagnosed on screening examination. Underlying, asymptomatic neural axis abnormalities may be present at the time of diagnosis. At certain institutions, total spine MRI is obtained preoperatively to identify these abnormalities. We provide a framework for the radiologist to follow while interpreting these studies. In part 1, we discuss Arnold Chiari malformations, syringomyelia, and the tethered cord. In part 2, we focus on spinal cord tumors, dysraphisms, to include diastematomyelia, and vertebral anomalies.

Prevalence of bifidity of the seventh cervical vertebral spinous process in southwestern Nigeria: a computed tomography based study

Palpation of the seventh cervical vertebra (C7) is an important landmark for counting vertebrae for vertebral spine surgical instrumentation. However, studies have shown that the spinous process of C7 displays an anatomical deviation among individuals, which may mislead a surgeon who is not aware of this, and there have been no such studies among southwest Nigerians. The present study aimed to examine the incidence of bifidity in the C7 spinous process and their variation among 48 subjects with the aid of a three-dimensional (3D) computed tomography. The 48 subjects who had undergone cervical spine computed tomography studies comprised the pooled data of ages between 12 and 55 years of black race in southwest Nigeria from the radiology department of the Trauma and Surgical Centre, Ondo State, Nigeria. A series of multivariate and discriminant statistical tests were performed on the measurement data to determine the occurrence of bifid spinous processes at C7 in southwestern Nigeria. The results show about 10% bifidity in the C-7 vertebra and no bifidity in the first cervical vertebra and the highest rate in the C-6 vertebra in the study population. The incidence in this study is significantly higher than findings in previous works. Thus, there is a need for clinicians to pay more attention to this variation when using C7 as a landmark especially in the studied population.

A cone beam computed tomographic analysis of cervical vertebral nonsegmentation

OBJECTIVE

Using cone beam computed tomography (CBCT), this study aimed to investigate the radiologic features of cervical vertebral nonsegmentation (CVN) in patients with no known syndromes or pathoses.

STUDY DESIGN

In this retrospective study, we examined CBCT scans of patients with CVN for the following parameters: type of nonsegmentation (partial or complete); laterality of partial nonsegmentation; level of vertebrae affected in nonsegmentation; anatomic parts of the vertebrae involved; and the presence or absence of degenerative joint disease (DJD).

RESULTS

From the structured reports of 13,458 CBCT scans, we found 110 CBCT scans (0.82%) with CVN. Of this total, 77.3% were partial and 22.7% were complete. Most were located at the level of the C2 and C3 vertebrae. The transverse process alone and the transverse process and body were most frequently involved in partial CVN, whereas most complete types occurred in the transverse process and body. Degenerative joint disease was present in 45.9% of partial CVN (clearly distinguishable from nonsegmentation in 36.5%) and 20% of complete CVN, with all cases clearly distinguishable.

CONCLUSIONS

Cervical vertebral nonsegmentation has a low prevalence. It is mostly partial, occurs most commonly in C2-C3, and usually involves the transverse process and body. Identification of CVN on CBCT images is important because this condition can lead to DJD in older age and may increase the risk for muscle weakness, head and neck pain, limited movement, and neurologic complications.

Exencephaly-Anencephaly Sequence Associated with Maxillary Brachygnathia, Spinal Defects, and Palatoschisis in a Male Domestic Cat

Anencephaly, a severe neural tube defect characterized by the absence of major parts of the brain and skull, is a rare congenital disorder that has been observed in various species, including cats. Considering the uncommon appearance of anencephaly, this paper aims to present anencephaly in a stillborn male kitten from an accidental inbreeding using various paraclinical methods. Histological examination of tissue samples from the cranial region, where parts of the skull were absent, revealed the presence of atypical nerve tissue with neurons and glial cells organized in clusters, surrounded by an extracellular matrix and with an abundance of blood vessels, which are large, dilated, and filled with blood, not characteristic of nerve tissue structure. In CT scans, the caudal part of the frontal bone, the fronto-temporal limits, and the parietal bone were observed to be missing. CT also revealed that the dorsal tubercle of the atlas, the dorsal neural arch, and the spinal process of the C2-C7 bones were missing. In conclusion, the kitten was affected by multiple congenital malformations, a combination of exencephaly-anencephaly, maxillary brachygnathism, closed cranial spina bifida at the level of cervical vertebrae, kyphoscoliosis, palatoschisis, and partial intestinal atresia. The importance of employing imaging techniques cannot be overstated when it comes to the accurate diagnosis of neural tube defects.

Pure spinal intraosseous arteriovenous fistula: A case report

Spinal osseous arteriovenous fistula (AVF) is a rare disease with a characteristic angioarchitecture involving an intraosseous venous pouch (VP) of the vertebral body where the feeders are converging. Using spinal angiography alone, it is difficult to distinguish spinal osseous AVF from classical spinal epidural AVF (EDAVF) with fistulas in the epidural VP and bone erosion because both subtypes have an angiographically similar dilated VP appearance. Thus, spinal osseous AVF may be often misdiagnosed as spinal EDAVF. With advancing imaging techniques, it would be possible to determine the exact location of the fistula. Here, we present the case of a 37-year-old woman with a pure spinal thoracic osseous AVF and radiculopathy. She was diagnosed with spinal intraosseous AVF using high-resolution three-dimensional rotational angiography (3D-RA). The fistula was located in the Th1 lateral mass with a VP where multiple osseous feeders were converging. There was paravertebral venous drainage without intradural venous drainage. Transvenous embolization with Onyx and coils was performed through the azygos vein to the lateral epidural venous plexus, resulting in complete obliteration. This case suggests that 3D-RA reconstructed images are essential for accurate diagnosis and successful treatment of this condition. It is important to occlude only intraosseous VPs by accurate subtype diagnosis. Transvenous embolization is a treatment option for spinal intraosseous AVF with paravertebral epidural venous drainage.

A case study on the pitfalls in prenatal ultrasonic detection of butterfly vertebra

Introduction

Butterfly vertebra is a rare congenital anomaly that is observed both in isolation and also as part of syndromic diseases. In prenatal ultrasonic scans the typical shapes of the two halves for butterfly vertebra are wedge-shaped or triangular. In the case we presented, the 3 dimensional computed tomography (3D CT) showed that the shape was unusual and rare. To improve the prenatal ultrasonic discriminability of this rare form of butterfly vertebra we used multi-directional ultrasonic images, corresponding to postpartum 3D CT images.

Case report

A 25-year-old woman was referred to our department for ultrasound screening. The routine fetal back spinal scan yielded findings indicative of an anomaly within the ninth thoracic vertebral body. The affected vertebra was examined by two-dimensional (2D) and three-dimensional (3D) ultrasound while the fetus was prone and supine. The focussed scanning of the fetal spine from the back, anterior and lateral approaches aided us to reach the final prenatal diagnosis of butterfly vertebra with asymmetric halves.The diagnosis of butterfly vertebra was confirmed by the radiologist with 3D CT after the woman chose to terminate the pregnancy due to multiple malformations. In 3D CT, the body of the ninth thoracic vertebra appeared to be two lateral halves of different sizes, and the bigger half was C-shaped. When prenatal ultrasonic images and postnatal CT images were compared, the echoic shape of the affected vertebra scanned from the front right side was very similar to the CT.

Conclusion

Due to the variable sizes and shapes of vertebrae affected in butterfly vertebra, prenatal diagnosis can be difficult using ultrasound. When the presence of fetal vertebral abnormalities is suspected, it is imperative for sonographers to adopt a comprehensive approach that extends beyond the conventional spinal examination performed solely from the dorsal aspect of the fetus. Instead, a thorough assessment should involve scanning the fetus from various angles, including anterior and lateral perspectives, in order to obtain a comprehensive and detailed evaluation of the identified vertebra.

Specialty Impact on Patient Outcomes: Paving a Way for an Integrated Approach to Spinal Disorders

Spinal surgical procedures are steadily increasing globally due to broad indications of certain techniques encompassing a wide spectrum of conditions, including degenerative spine disorders, congenital anomalies, spinal metastases, and traumatic spinal fractures. The two specialties, neurosurgery (NS) and orthopedic surgery (OS), both possess the clinical adeptness to perform these procedures. With the advancing focus on comparative effectiveness research, it is vital to compare patient outcomes in spine surgeries performed by orthopedic surgeons and neurosurgeons, given their distinct approaches and training backgrounds to guide hospital programs and physicians to consider surgeon specialty when making informed decisions. Our review of the available literature revealed no significant difference in postoperative outcomes in terms of blood loss, neurological deficit, dural injury, intraoperative complications, and postoperative wound dehiscence in procedures performed by neurosurgeons and orthopedic surgeons. An increase in blood transfusion rates among patients operated by orthopedic surgeons and a longer operative time of procedures performed by neurosurgeons was a consistent finding among several studies. Other findings include a prolonged hospital stay, higher hospital readmission rates, and lower cost of procedures in patients operated on by orthopedic surgeons. A few studies revealed lower sepsis rates unplanned intubation rates and higher incidence of urinary tract infections (UTIs) and pneumonia postoperatively among patient cohorts operated by neurosurgeons. Certain limitations were identified in the studies including the use of large databases with incomplete information related to patient and surgeon demographics. Hence, it is imperative to account for these confounding variables in future studies to alleviate any biases. Nevertheless, it is essential to embrace a multidisciplinary approach integrating the surgical expertise of the two specialties and develop standardized management guidelines and techniques for spinal disorders to mitigate complications and enhance patient outcomes.

Prenatal and Neonatal Ultrasound and Magnetic Resonance Imaging Diagnosis of Sprengel's Deformity with Unusual Associations

INTRODUCTION

Sprengel's deformity is a rare congenital anomaly of the shoulder rim. It is the most common congenital anomaly of the shoulder, associated with cosmetic deformity and abnormal shoulder function. Nonsurgical management can be considered for mild cases. Surgical intervention is indicated in moderate to severe cases with the goal of improving cosmetic appearance and function. The best surgical results are obtained in children aged 3-8 years. Correct diagnosis is very important because Sprengel's deformity can be accompanied by additional abnormalities, even in mild cases, and lack of a diagnosis delays proper treatment of the child. The severity of the defect may progress, so it is important to correctly identify children with Sprengel's deformity, even those with a mild form of the defect.

CASE PRESENTATION

We report a case of prenatal sonographic diagnosis of Sprengel's deformity with additional features, as yet undescribed and missed - although visible - on prenatal magnetic resonance imaging (MRI). Cesarean delivery was performed due to preterm rupture of membranes, and a postnatal MRI confirmed the unusual constellation of Sprengel's anomaly with lateral meningocele, vestigial posterior meningocele, and lipoma tethering of the cord to the dural sac at the cervical-thoracic junction.

CONCLUSION

Diagnosis of Sprengel's deformity is possible with prenatal ultrasound. Asymmetry of the cervical spine, discontinuity of the vertebral arch and abnormal vertebral bodies, as well as the asymmetric position of the shoulder blades with the presence of an omovertebral bone are signs that can help diagnose the defect.

Incidental osseous lesions on chest CT: an algorithmic approach for radiologists

Numerous osseous findings are commonly discovered incidentally at chest CTs in daily practice. A broad spectrum of these findings ranges from benign and do not touch lesions to ominous conditions requiring further imaging evaluation and/or intervention. Interpretation of these incidental musculoskeletal findings may constitute a diagnostic challenge to radiologists. This review provides a systematic, algorithmic approach to common osseous lesions on chest CT based on imaging findings with recommendations for proper next step management.

Sacralization of Coccygeal Vertebra: A Descriptive Observational Study in Bangladesh

Background: In the sacrococcygeal region, anatomical variation is due to the sacralization of the coccygeal vertebra, which is the due union of/fusion of the fifth sacral with the first coccygeal vertebra of five couples of sacral foramina under-detected or asymptomatic beyond radiological assessment. That is why it is challenging to know the cause of coccydynia, caudal block failure, the difficult second stage of labor, and perineal tears. The present study aims to improve knowledge about the anatomical variation of sacralization of the coccygeal vertebra. Additionally, to find the prevalence of sacralization of coccygeal vertebra in Sylhet, Bangladesh.

Methods: This study was performed on 60 parched, totally calcified, typical sacra of mature-age individuals of undetermined sexes, fulfilling the inclusion criteria from the bone bank of the osteology museum of the Department of Anatomy, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh, from July 2017 to June 2018. Sex determination of the collected unknown sacra was conducted using discriminant function analysis. It was found that 50% (30) were male and 50% (30%) were female. The unpaired t-tests and chi-square were utilized to determine the statistical significance.

Results: Out of 60 sacra, eight (13.33%) samples presented with sacralization. This study found that males had significantly higher straight (p=0.05) and curved (p=0.05) lengths of sacrococcygeal vertebrae. The sacrococcygeal curvature index (SCI) showed statistically significant (p=0.05) differences between the sexes.

Conclusion: Sacralization may exert an impact on the caudal block. It could extend the second stage of the labor process with perineal tears. Therefore, knowledge about the anatomical variation of the coccygeal vertebra is essential.

The value of magnetic resonance imaging and computed tomography in the study of spinal disorders

Computed tomography (CT) and magnetic resonance imaging (MRI) have replaced conventional radiography in the study of many spinal conditions, it is essential to know when these techniques are indicated instead of or as complementary tests to radiography, which findings can be expected in different clinical settings, and their significance in the diagnosis of different spinal conditions. Proper use of CT and MRI in spinal disorders may facilitate diagnosis and management of spinal conditions. An adequate clinical approach, a good understanding of the pathological manifestations demonstrated by these imaging techniques and a comprehensive report based on a universally accepted nomenclature represent the indispensable tools to improve the diagnostic approach and the decision-making process in patients with spinal pain. Several guidelines are available to assist clinicians in ordering appropriate imaging techniques to achieve an accurate diagnosis and to ensure appropriate medical care that meets the efficacy and safety needs of patients. This article reviews the clinical indications of CT and MRI in different pathologic conditions affecting the spine, including congenital, traumatic, degenerative, inflammatory, infectious and tumor disorders, as well as their main imaging features. It is intended to be a pictorial guide to clinicians involved in the diagnosis and treatment of spinal disorders.

Vertebral anomalies in a natural population of Taricha granulosa (Caudata: Salamandridae)

Developmental plasticity, a common pattern in lissamphibian evolution, results in numerous alternative morphologies among species and also within populations. In the present study, a natural population of the salamander Taricha granulosa (Salamandridae) was examined to detect variation in the vertebral count and to identify potential deformities of their vertebral column. The number of trunk vertebrae varied between 11 and 13 and we recorded 58 individuals with 69 anomalous vertebral elements. These anomalies range from congenital malformations (block vertebrae, unilateral bars, hemivertebrae), extra ossifications in the haemal region, to posttraumatic pathologies. Most osseous pathologies were encountered in the caudal region of the axial skeleton. Our data suggest a high frequency of vertebral malformations in salamanders; however, the identification of the exact causes remains challenging.

Birth defect co-occurrence patterns in the Texas Birth Defects Registry

BACKGROUND

The population-level landscape of co-occurring birth defects among infants without a syndromic diagnosis is not well understood.

METHODS

We analyzed data from 40,771 infants with two or more major birth defects in the Texas Birth Defects Registry (TBDR; 1999-2014). We calculated adjusted observed-to-expected (O/E) ratios for all two, three, four, and five-way combinations of 138 major defects.

RESULTS

Among 530 patterns with the highest adjusted O/E ratios (top 5% of 10,595 patterns), 66% included only defects co-occurring within one organ system and 28% were suggestive of known patterns (e.g., midline developmental defects). Of the remaining patterns, the combination of defects with the highest O/E ratio (193.8) encompassed the diaphragm, spine, spleen, and heart defects. Fourteen patterns involved heart and spine defects with or without rib defects. Ten additional patterns primarily involved two hallmark components of VACTERL association (specifically, vertebral defects, anal atresia, cardiac defects, renal, or limb defects, but not tracheoesophageal fistula).

CONCLUSIONS

Our analyses provide a description of the birth defect co-occurrence patterns in a multi-ethnic, population-based sample, and revealed several patterns of interest. This work complements prior work that has suggested etiologic connections between select defects (e.g., diaphragmatic hernia and heart and spleen anomalies; heart and spine defects).

IMPACT

In this large-scale, population-based study of birth defect co-occurrence patterns, we found several birth defect combinations of potential interest that warrant further investigation: congenital diaphragmatic hernia, heart, spine, and spleen defects and scimitar syndrome with vertebral defects. The majority of patterns of co-occurring defects observed more frequently than expected involved multiple defects within the same system and combinations suggestive of known associations. Nearly all of the top patterns (beyond the same system and those suggestive of known associations) involved organ systems that are components of the VACTERL association, with heart, spine, and rib defect patterns being the most common.

First-Trimester Diagnosis of Supernumerary Hemivertebra

Hemivertebra is a common cause of congenital scoliosis and results from a lack of formation of one-half of the vertebral body. This condition is very rare and can present as solitary or as a syndrome component: i.e., the split notochord syndrome, which often implies vertebral defects, from a bifid vertebra to hemivertebrae, or fused vertebrae. We describe a case of supernumerary lateral hemivertebra detected prenatally at 12 weeks of gestation and the ultrasonography specifics that lead to early and accurate diagnosis, monitoring during pregnancy, and follow-up at the 4-year period. The case is presented to specify the importance of an early assessment of fetal spine and diagnosis of various conditions, including hemivertebrae, considering the significant association with other anomalies (cardiovascular, urinary, skeletal, gastrointestinal, and central nervous systems), which are most commonly involved. Moreover, the need to counsel future parents on the risks implied by this anomaly is important for the obstetrician. We underline the inclusion of these types of congenital conditions in high-risk pregnancy because of the frequent association with high cesarean delivery rates, growth restriction, delivery before term, and higher morbidity rates.

Ontogeny of morphological variations in the vertebral column: Prevalence and bony variability in young Spanish children

Pre- and postnatal development and variability in discrete vertebral traits have been poorly described in embryonic studies. Numerous authors have reported that these variations are observable only from adolescence; scientific publications on the vertebrae of fetuses and infants are scarce. Thus, the aims of this study were to (1) describe the ontogeny and variability of anatomical variations in the vertebral column of a Spanish infant population and (2) analyze the frequency and relationship between sex, age, and intertrait variables. A total of 4728 vertebrae from 197 skeletons were studied. The age at death ranged from 22 intrauterine weeks to 8 years. Twenty morphological traits related to vertebral column development were analyzed. A descriptive statistical analysis was performed, and the chi-square test was used to measure the relationship between sex, age, and intertrait variables. We observed that 88.32% of skeletons expressed discrete traits along the spine. In fetuses, the double transverse foramen and unclosed transverse process of the axis were the most prevalent traits. In infants older than one year, the appearance of the L5 cleft neural arch, unclosed transverse process of the atlas, and craniocaudal shifts were frequent. A significant result was found between sex and the unclosed transverse process in the axis. The intertrait relationship was significant for all traits that shared the same embryonic structure. Morphological variations became visible following the appearance of ossification centers during the pre- and postnatal periods, and their etiology was associated with embryonic development.

Correlation between the lateral and anteroposterior sacral ratios in anorectal malformations

BACKGROUND

The sacral ratio has been used as a tool for evaluating sacral development in patients with anorectal malformations. Sacral ratios can be calculated by obtaining sacral radiographs in the anteroposterior (AP) and lateral planes.

OBJECTIVE

The objective of the study was to determine the correlation and agreement in sacral ratio calculations.

MATERIALS AND METHODS

In this single institution retrospective cohort study, we reviewed medical charts of all pediatric anorectal malformation patients treated between March 2014 and September 2018 who had both AP and lateral images of their sacrum. All sacral ratios were measured by three radiologists. Pearson's correlation coefficients and corresponding 95% confidence intervals (CIs) were used to assess the correlation between the AP and lateral radiographs. A weighted Kappa statistic was used to measure the agreement between how the AP and lateral sacral ratios categorized observations into risk groups.

RESULTS

Our initial cohort consisted of 646 observations from patients with anorectal malformations who had radiographs obtained in both AP and lateral planes. We excluded all observations (n=76) where the radiographs were deemed to be inadequate or not appropriately centered to measure sacral ratio. For a given pair of measurements, the mean lateral sacral ratio was 0.07 units greater than the AP plane (95% CI 0.06-0.09, paired t-test P-value <0.0001). AP and lateral images had a moderate positive correlation (Pearson's r=0.76, 95% CI 0.73-0.79, P<0.0001) and moderate agreement in risk categorization (unweighted kappa = 0.60, P<0.0001). AP and lateral readings conducted by all three radiologists had excellent inter-rater reliability with intraclass correlations for AP and lateral sacral ratios of 0.88 and 0.84, respectively.

CONCLUSION

Even though the AP and lateral sacral ratios had moderate positive correlation, the mean sacral ratio determined by images in the lateral plane was 0.07 units greater than the AP plane. AP and lateral sacral ratios concluded different risk categories relatively often. Future studies are needed to determine whether AP or lateral sacral ratios correlate better with continence in patients with anorectal malformations.

Investigation of Genetic Causes in a Developmental Disorder: Oculoauriculovertebral Spectrum

OBJECTIVE

Oculoauriculovertebral spectrum (OAVS) is a genetically and clinically heterogeneous disorder that occurs due to a developmental field defect of the first and second pharyngeal arches. Even though recent whole exome sequencing studies (WES) have led to identification of several genes associated with this spectrum in a subset of individuals, complete pathogenesis of OAVS remains unsolved. In this study, molecular genetic etiology of OAVS was systematically investigated.

DESIGN/SETTING/PATIENTS

A cohort of 23 Turkish patients with OAVS, referred to Hacettepe University Hospital, Department of Pediatric Genetics from 2008 to 2018, was included in this study. Minimal diagnostic criteria for OAVS were considered as unilateral microtia or hemifacial microsomia with preauricular skin tag. The cohort was clinically reevaluated for craniofacial and extracranial findings. Molecular etiology was investigated using candidate gene sequencing following copy number variant (CNV) analysis. WES was also performed for 2 of the selected patients.

RESULTS

Patients in the study cohort presented similar demographic and phenotypic characteristics to previously described patients in the literature except for a higher frequency of bilaterality, cardiac findings, and intellectual disability/developmental delay. CNV analysis revealed a possible genetic etiology for 3 patients (13%). Additional WES in 1 of the 2 patients uncovered a novel heterozygous nonsense variant in Elongation factor Tu GTP-binding domain-containing 2 (EFTUD2) causing mandibulofacial dysostosis with microcephaly (MFDM), which clinically overlaps with OAVS.

CONCLUSION

Detailed clinical evaluation for any patient with OAVS is recommended due to a high rate of accompanying systemic findings. We further expand the existing genetic heterogeneity of OAVS by identifying several CNVs and a phenotypically overlapping disorder, MFDM.

Right-sided Zinner syndrome with a left side quadrupled ureter- a case report

Zinner syndrome is a rare congenital anomaly of the genitourinary tract, consisting of ipsilateral renal agenesis, seminal vesicle cysts, and ejaculatory duct obstruction. Besides, quadruplication of the ureter is the rarest anomaly composed of proximal four ureters ending with a single distal ureter. The authors present an adult male patient with left flank pain and dysuria who was referred for abdomen CT scan. The CT scan revealed renal agenesis, seminal vesicle cysts, and obstructed ejaculatory duct, all in the right side (Zinner syndrome), and quadruplication of the ureter on the left side. The additional finding of hemivertebra was present resulting in kyphoscoliosis. Zinner syndrome and quadrupled ureter, are both rare anomalies, and the occurrence of both entities at the same patient is exceptionally rare, and have not been reported yet in the English literature. Furthermore, standard treatment protocols have to be pursued, as such patients hold a single kidney with the quadrupled ureter.

The Pediatric Spine

The spine, a frequently investigated site in children, has a complex development in relation to both nervous and bone/cartilaginous structures and shows several particular features in children compared with adults. We report the main normal variants and pathologies of the pediatric spine, from the prenatal period to adolescence, focusing on a multimodality imaging approach.

Axial Spondyloarthritis: Mimics and Pitfalls of Imaging Assessment

Axial spondyloarthritis (axSpA) is a chronic inflammatory disorder that predominantly involves the axial skeleton. Imaging findings of axSpA can be divided into active changes, which include bone marrow edema, synovitis, enthesitis, capsulitis, and intra-articular effusion, and structural changes, which include erosions, sclerosis, bone fatty infiltration, fat deposition in an erosion cavity, and bone bridging or ankylosis. The ability to distinguish between imaging lesions suggestive of axSpA and artifacts or lesions suggestive of other disorders is critical for the accurate diagnosis of axSpA. Diagnosis may be challenging, particularly in early-stage disease and magnetic resonance imaging (MRI) plays a key role in the detection of subtle or inflammatory changes. MRI also allows the detection of structural changes in the subchondral bone marrow that are not visible on conventional radiography and is of prognostic and monitoring value. However, bone structural changes are more accurately depicted using computed tomography. Conventional radiography, on the other hand, has limitations, but it is easily accessible and may provide insight on gross changes as well as rule out other pathological features of the axial skeleton. This review outlines the imaging evaluation of axSpA with a focus on imaging mimics and potential pitfalls when assessing the axial skeleton.

The role of radiography in the study of spinal disorders

Despite the growing use of computed tomography (CT) and magnetic resonance imaging (MRI) in the study of spinal disorders, radiography still plays an important role in many conditions affecting the spine. However, the study and interpretation of spine radiograph is receiving less attention and radiologists are increasingly unfamiliar with the typical findings in normal and pathologic conditions of the spine. The aim of this article is to review the radiologic indications of radiograph in different pathologic conditions that affect the spine, including congenital, traumatic, degenerative, inflammatory, infectious and tumour disorders, as well as their main radiographic manifestations.

Anatomical Variations That Can Lead to Spine Surgery at the Wrong Level: Part III Lumbosacral Spine

Spine surgery at the wrong level is an undesirable event and unique pitfall in spine surgery. It is detrimental to the relationship between the patient and the surgeon and typically results in profound medical and legal consequences. It falls under the wrong-site surgery sentinel events reporting system. This error is most frequently observed in lumbosacral spine. Several risk factors are implicated; however, anatomical variations of the lumbosacral spine are a major risk factor. The aim of this article was to provide a detailed description of these high-risk anatomical variations, including transitional vertebrae, lumbar ribs, butterfly vertebrae, hemivertebra, block/fused vertebrae, and spinal dysraphism. A literature review was performed in the database PubMed to obtain all relative English-only articles concerning these anatomical variations and their implication in the development of lumbosacral spine surgery at the wrong level. We also described patient characteristics that can lead to lumbosacral surgery at the wrong level such as tumors, infection, previous lumbosacral surgery, obesity, and osteoporosis. Certain techniques to prevent such incorrect surgery were explained. Lumbosacral spine anatomical variations are surgically significant. Awareness of their existence may provide better pre-operative planning and surgical intervention, leading to avoidance of incorrect-level surgery and potentially better clinical outcomes. In addition, collaboration with radiologists and careful examination of patient’s anatomy and characteristics should be exercised, especially in difficult cases.

Anatomical Variations That Can Lead to Spine Surgery at The Wrong Level: Part II Thoracic Spine

Spine surgery at the wrong level is a detrimental ordeal for both surgeon and patient, and it falls under the wrong-site surgery sentinel events reporting system. While there are several methods designed to limit the incidence of these events, they continue to occur and can result in significant morbidity for the patient and malpractice lawsuits for the surgeon. In thoracic spine, numerous risk factors influence the development of this misadventure. These include anatomical variations such as transitional vertebrae, rib variants, hemivertebra, and block/fused vertebrae as well as patient characteristics, such as tumors, infections, previous thoracic spine surgery, obesity, and osteoporosis. An extensive literature search of the PubMed database up to 2019 was completed on each of the anatomical entities and their influence on developing thoracic spine surgery at the wrong level, taking into consideration patient’s individual factors. A reliable protocol and effective techniques were described to prevent this error. In addition, the surgeon should collaborate with radiologists, particularly in challenging cases. A thorough understanding of the surgical anatomy and its variants coupled with patients characteristic is crucial for maximal patient benefit and avoidance of thoracic spine surgery at the wrong level.

Anatomical Variations That Can Lead to Spine Surgery at the Wrong Level: Part I, Cervical Spine

Spine surgery at the wrong level is an adversity that many spine surgeons will encounter in their career, and it falls under the wrong-site surgery sentinel events reporting system. The cervical spine is the second most common location in the spine at which surgery is performed at the wrong level. Anatomical variations of the cervical spine are one of the most important incriminating risk factors. These anomalies include craniocervical junction abnormalities, cervical ribs, hemivertebrae, and block/fused vertebrae. In addition, patient characteristics, such as tumors, infection, previous cervical spine surgery, obesity, and osteoporosis, play an important role in the development of cervical surgery at the wrong level. These were described, and several effective techniques to prevent this error were provided. A thorough review of the English-language literature was performed in the database PubMed between 1981 and 2019 to review and summarize these risk factors. Compulsive attention to these factors is essential to ensure patient safety. Therefore, the surgeon must carefully review the patient's anatomy and characteristics through imaging and collaborate with radiologists to reduce the likelihood of performing cervical spine surgery at the wrong level.

Tethered cord syndrome and transitional vertebrae

PURPOSE

Tethered cord syndrome (TCS) usually presents with low-lying conus medullaris and thickened filum terminale. Spinal cord anomalies usually accompany congenital malformations and variations of the vertebral column. Transitional vertebrae (TV) are common variant, especially in the lumbosacral region. Accurate definition of the spine level is essential for proper radiological diagnosis and treatment. In this study, congenital spinal cord and vertebral anomalies and the relation with TV groups and types were evaluated in TCS patients.

METHODS

The study was performed in 97 patients. Radiological imaging findings [computed tomography (CT), magnetic resonance imaging (MRI), and radiography] and medical records were evaluated. Spine bony malformation, spinal cord malformation, and spinal level of malformation were compared with TV and non-TV groups in TCS patients. In addition, TV groups and types were compared with each other for these anomalies.

RESULTS

There was no statistically significant difference between TV and non-TV group in terms of the presence of vertebral bone and spinal cord anomalies. There were some significant differences in some of the spine bone and spinal cord anomalies among the groups and types of TV.

CONCLUSION

Sixty-two point nine percent TCS patients had TV. Although these findings indicate that TV is common in patients with TCS, no significant difference is observed in most of the studied anomalies. However, there were some differences among the TV groups and TV types in relation to congenital malformations. It can be concluded that TV anomaly could be a distinct malformation apart from all the other anomalies that were studied. Transitional vertebrae may cause pain due to biomechanical changes in addition to progressive neurological symptoms which are usually seen with TCS.