Case Study 2 – Navigating the Complexity: A Comprehensive Analysis of Craniocervical Instability Imaging Studies and Common Comorbidities for Patient “Patrice Ho” (June 2024)
DISCLAIMER: The name “Patrice Ho” has been used in the following case study to protect the anonymity of the individual. Actual names have not been used and the report summaries have been modified to ensure the privacy and confidentiality of the individual.
SUMMARY
“Patrice Ho”, a 45-year-old patient, presented with symptoms suggestive of craniocervical instability after a motor vehicle accident (MVA). A series of imaging studies were conducted to assess the condition comprehensively. The findings from each study completed by Spine and Brain Advocate’s Craniocervical Instability (CCI) Radiology experts revealed a complex interplay of degenerative changes, anatomical variations, and potential indicators of instability. This summary aims to consolidate the results of these studies and provide insights into the imaging diagnostic process.
IMAGING REPORTS SUMMARY OF FINDINGS
Radiographs/X-Ray of Cervical Spine (Study #1):
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- Straightening / loss of the cervical lordosis.
- Degeneration:
- Anterior and posterior marginal osteophytes are seen along the C3, C4, C5, C6, and C7 vertebral bodies, most marked at C4, C5, and C6 vertebral bodies with the reduction in the heights of the intervertebral disc spaces at C4-C5, C5-C6, and C6-C7 levels with adjacent end plate sclerosis and reduction in right C2-C3 facet joint with sclerosis.
- Reduction in the uncovertebral joint spaces with adjacent periarticular osteophytes and sclerosis seen at multiple uncovertebral joint levels suggestive of uncovertebral osteoarthritis with narrowing of the left neural foramen at C4-C5 level.
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Dynamic Motion X-ray (DMX) Cervical Spine (Study #2):
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- Loss of the normal cervical lordosis.
- Reduced C5-C6 intervertebral disc space and anterior lipping and osteophyte in C5 vertebral body.
- Lateral translation C1-C2 during left and right lateral bending suggestive of mild laxity of the right > left alar ligaments and transverse atlantal ligament (TAL)
- Moderate anterior and posterior translation (slipping/instability) of C3 over C4 during flexion and extension respectively.
- Intersegmental hypomobility of C5-C6 during flexion – likely due to myospasm (muscle contraction, possibly due to injury, instability or degeneration).
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MRI Cervical Spine (Study #3):
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- Normal study of cranio-cervical junction.
- Degeneration:
- Cervical spondylotic changes (see full report for details).
- Moderate diffuse disc bulge in C5-C6 & C6-C7 IV-discs causing minimal indentation on thecal sac.
- Small postero-central disc protrusion in C7-T1 IV-disc indenting on anterior thecal sac.
- Small synovial / ganglion cyst in the postero-medial aspect of left temporomandibular joint.
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Contrast-Enhanced MRI Brain with MR Angiography (Study #4):
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- Small vessel ischemic changes in the brain – Fazekas grade 1 white matter changes.
- Mild prominence of frontal cortical sulci and the subarachnoid spaces – possibly due to atrophy.
- Reduced height of pituitary gland with concave superior surface – suggestive of partial empty sella. This finding is suspicious of intracranial hypertension.
- Anteroposterior flattening of the bilateral internal jugular veins at the level of the transverse process of C1, although this sequence is limited in its capacity to rule out styloid venous compression. Suggest dynamic Venography of the head and neck for further evaluation.
- Normal MR Angiography of the head and neck except for a few anatomical variants and mild tortuosity of the vertebrobasilar system as described in full in the report.
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Dynamic MRI Cervical Spine with Flexion-Extension (Study #5):
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- Straightening of cervical lordosis with multi-level disc dehydration.
- Translational Basion-Axis interval falls in the pathological range. This raises concern for the presence of cranio-cervical instability.
- The Grabb-Oakes measurement is borderline increased in the flexion position; however, it falls within the normal range on neutral and extension positions. This also raises a potential concern for cranio-cervical instability.
- All other measurements of the craniocervical junction are normal.
- There is minimal grade I anterolisthesis (forward slippage/instability) of C3 over C4 vertebra in the flexion position as noted also in DMX. However, no remarkable translation is visible on neutral or extension positions. This is suggestive of segmental anterior translational instability for flexion at this level.
- Degeneration:
- Anterior lipping with osteophyte formation and anterior disc osteophyte complex at C5-C6 level, along with Modic type I degenerative changes and reduced disc height.
- Small left foraminal disc protrusion at C4-C5 level causing mild compression of the ipsilateral exiting C4 nerve root, which is slightly accentuated by the left uncovertebral joint hypertrophy.
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Dynamic Cone Beam CT Cervical Spine (Study #6):
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- Findings consistent with moderate to severe median atlanto-dental and mild bilateral lateral atlanto-axial osteoarthritis as described in detail in the full report. (Note: This was the first imaging to pick up atlantoaxial osteoarthritis – meaning, XRay and DMX study quality was not good enough)
- All measurements of the craniocervical junction in neutral, flexion and extension are normal.
- Degenerative changes in the visualized subaxial cervical spine with flattening of the upper cervical lordosis, subtle right-ward inclination, multilevel osteophytosis and disc degeneration as described in the full report in detail.
- Elongation of bilateral styloid processes as described; correlation with clinical features is recommended for further management. (Note: This was not picked up in any other prior study i.e. XRay, DMX, MRI)
- Incidental mild deviation of the nasal septum to the left with bony spur impinging on the left inferior turbinate.
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Contrast-Enhanced Dynamic MR Angiography of Neck (Study #7):
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- There is mild physiological narrowing of the internal jugular veins adjacent to the C1 vertebra. (Note: This ties in with the MRI/MRA Brain finding “Anteroposterior flattening of the bilateral internal jugular veins at the level of the transverse process of C1”)
- No significant abnormality of the major neck vessels is detected in the present study. The physiological findings and anatomical variants are as described in the full report above.
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Head and Neck CT Venography with CT Cervical Spine (Study #8):
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- Moderate to severe median anterior and bilateral lateral atlanto-axial osteoarthritis as described in the full report with no features concerning for craniocervical instability in the present scan.
- Degenerative changes in the visualized subaxial cervical spine with flattening of the upper cervical lordosis, subtle right-ward inclination, multilevel osteophytosis, reduced intervertebral disc spaces and uncovertebral and facet joint arthritis as described in the full report in detail.
- Borderline elongation of bilateral styloid processes as described; correlation with clinical features is recommended for further management.
- Incidental mild deviation of the nasal septum to the left with bony spur impinging on the left inferior turbinate.
- Left sigmoid sinus dehiscence.
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CONCLUSION
The combination of imaging studies for “Patrice Ho” revealed a spectrum of findings indicative of craniocervical instability and associated comorbidities. The overlapping as well as differing results across imaging studies underscore the importance of utilizing multiple modalities to capture the complexity of the condition fully. The presence of degenerative changes (especially highlighted in CBCT/CT studies), ligament laxity in dynamic imaging studies, and potential instability markers necessitates a comprehensive approach to diagnosis and management.
CT or Cone Beam CT scans are valuable for assessing bone structures and detecting acute conditions like fractures, osteoarthritis or bleeding, while MRI (Magnetic Resonance Imaging) is excellent for visualizing soft tissues, such as muscles, spinal cord and the brain, making it ideal for evaluating chronic conditions and neurological disorders. A venogram specifically evaluates your veins, whereas an angiogram evaluates arteries or veins. Dynamic imaging is invaluable in assessing spinal and craniocervical instability. Each imaging modality has its strengths, and is chosen based on the specific clinical question and the type of tissue or pathology being investigated.
Further investigations, such as CSF flow study, and dynamic imaging of internal jugular veins, are recommended for “Patrice Ho” to evaluate intracranial dynamics and venous abnormalities more thoroughly. The significance of dynamic imaging in assessing instability and the need for a multidisciplinary approach involving neurology, radiology, neurovascular and neurosurgery are highlighted in this case. Patrice Ho’s case exemplifies the intricate nature of craniocervical instability and emphasizes the value of a detailed imaging evaluation in guiding clinical decision-making and treatment planning.
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