Tag Archives: spine

Spinal Fractures in AS vs. DISH

14 Jan

submitted by Matthew Kongkatong, M.D.


Ankylosing spondylitis:

-Chronic inflammation of the spine causes progressive ossification of the paraspinous ligaments

-Prevalence 0.1%-1.4%



AS: “bamboo spine”, ossification of disc spaces


Diffuse Idiopathic Skeletal Hyperostosis (DISH):

-Non-inflammatory process of known etiology causes progressive ossification of paraspinous ligaments.

-Prevalence varies 2.9%-25%

-Associated with obesity, advanced age, and diabetes mellitus


DISH: “flowing candle wax”, preserved disc spaces


Spine fractures in DISH and AS

-Review article of 93 papers including 345 AS patients and 66 DISH patients

65% of AS and 69% of DISH patients sustained fractures via low energy mechanisms life falling from sitting or standing

Most (80% in AS and 60% in DISH) fractures were in the cervical spine and most were hyperextension type injuries.

-67% of AS and 40% of DISH patients had a neurologic deficit on presentation and 13% of AS and 15% of DISH patients had neurologic deterioration ❤ months from presentation (compared to 0.08% in other population studies).

Most spine fractures are considered unstable because they extend into calcified ligaments and surrounding soft tissue, including into the intervertebral discs.

Calcified ligaments can transmit force and cause fractures in areas remote from the area of trauma.

References: Westerveld LA, Verlaan JJ, Oner FC: Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications. Eur Spine J 2009, 18:145-156.; http://www.orthobullets.com/spine/2045/dish-diffuse-idiopathic-skeletal-hyperostosis


Vertebral Osteomyelitis/Discitis

23 Dec

submitted by Amit Kumar, M.D.


3 main mechanisms of infection:

  • Hematogenous spread
  • direct inoculation (trauma, spinal surgeries/procedures)
  • contiguous spread from adjacent tissues



  • Staph aureus (>50%)
  • enteric gram-neg bacilli (following GU procedures)
  • psuedomonas/candida (often due to IV sepsis or IVDU)
  • group B strep (esp. in diabetics)

Signs & symptoms:

  • Localized spinal pain
  • leukocytosis
  • elevated ESR/CRP
  • fever
  • new radicular symptoms

Diagnostic strategies: Blood culture, MRI (most sensitive radiologic technique), biopsy (open/CT guided)

Differentials: Spinal epidural abscess, psoas abscess, herniated disc, spinal metastasis, vertebral compression fracture

Treatment: Pain control, ANTIBIOTICS (empiric followed by pathogen-directed. Routinely for minimum of 6 weeks), surgery (indications: neuro deficits, abscess needing drainage, cord compression)


  • Posterior extension leading to epidural/subdural abscess or meningitis.
  • Anterolateral extension leading to paravertebral/psoas abscess.

***Picture: High signal is T2-weighted MRI at the disc and adjacent vertebral body compatible with diagnosis





word of the day: pneumorrhachis!

2 Dec

from a recent JEM article by Aiyappan et al.  

Case report of a 53 yo M complaining of facial and chest puffiness.  Had a hx of asthma.  X-ray/CT showed mediastinal air and subcutaneous emphysema, and also….



= intraspinal air

-> rare, can extend from posterior mediastinum into the dural space through the neural foramen.

-> can be asymptomatic, but watch out for cord compression symptoms


For some more depth, check out this 2006 review of this rare phenomenon.


References: case report, 2006 review; picture

Prevertebral soft tissue swelling on MRI, now what?

1 Mar


Your next patient is a 62 year old female without significant past medical history with 2 weeks of neck pain, progressively worsening over past 5 days.

Denies trauma, recent infections, dental problems, or surgeries.

Reports pain worse with movements and swallowing and not relieved with Tylenol.

Afebrile, well appearing, normal vital signs, decreased range of motion of neck in all directions. Normal ENT exam; Normal Neuro exam; no loss of bladder/bowel function.

worst case neck badness DDx: osteomyelitis, spinal/epidural abscess, retropharyngeal abscess, spinal stenosis, etc.

So someone orders an MRI: “Prevertebral soft tissue swelling from C2 through C6 levels. The findings could be due to infectious etiology.”  

But no abscess/surgical lesion on the MRI.  hmmmm…..


Now what?

XR C-Spine: Upper cervical prevertebral soft tissue swelling associated with amorphous calcification anterior to C2 vertebral body

Boom! Acute Calcific Tendinitis

Prevertebral acute calcific tendinitis was originally described in 1964 by Hartley and subsequently shown to be due to hydroxyapatite deposition by Ring and colleagues in 1994. Longus colli are bilateral neck flexors which make up bulk of prevertebral space along with longus capitus. Divided from retropharyngeal space, composed of fatty tissue and lymph nodes, by middle layer of deep cervical fascia.

Retropharyngeal space is prone to infections in children, immunocompromised, and patients with penetrating neck injuries.  Causes of acute calcific tendinitis are still unclear.

Importance: Aggressive management, often involving surgery and long-term antibiotics, of retropharyngeal and spinal abscesses is required as they still carry significant morbidity and mortality.

XR as compared to MRI can help differentiate acute calcific tendinitis (due to the calcium deposition) from other inflammatory processes.

Criteria for diagnosing prevertebral acute calcific tendinitis is as follows:

  • Fluid smoothly expands retropharyngeal space in all directions
  • Absence of enhancing wall around fluid
  • Absence of purative retropharyngeal space lymph nodes with low-attenuation centers
  • Pathognomonic tendinous calcifications within the longus colli

Submitted by K. Dabrowski.

References: Eastwood JD, Hudgins PA, Malone D. Retropharyngeal effusion in acute calcific prevertebral tendonitis: Diagnosis with CT and MR imaging. AJNR Am J Neuroradiol. 1998;19:1789-1792.; picture