(Radiology. 2001;220:191-194.)
© RSNA, 2001
Case 36: Bilateral Cervical Spondylolysis of C61
Joel M. Schwartz, MD
1 From the Department of Radiology, Nyack Hospital, 160 N Midland Ave, Nyack, NY 10960. Received February 19, 1999; revision requested April 10; final revision received November 8; accepted November 24. Address correspondence to the author (e-mail: joel.schwartz@worldnet.att.net).
Index terms: Diagnosis Please • Neck, abnormalities, 31.423 • Neck, CT, 31.1211 • Neck, MR, 31.1214 • Neck, radiography, 31.11 • Spine, facet joints, 31.423 • Spondylolysis, 31.423
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HISTORY
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A 34-year-old woman presented to the emergency department after a motor vehicle accident. She was the driver in a head-on collision at approximately 25 miles per hour. She complained of mild nonfocal neck tenderness without a radicular component or numbness, and she described sporadic episodes of nonfocal neck pain before the motor vehicle accident. Physical examination revealed third-degree burns over the anterior neck bilaterally secondary to her inflated supplemental restraint system (air bag). Her neck had full range of motion. Neurologic examination results were normal. Radiographs of the cervical spine were obtained (Fig 1).
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Figure 1a. (a) Lateral radiograph of cervical spine in extension. Note the well-corticated defect (long arrow) between the superior and inferior articular pillars of C6 bilaterally and the grade I spondylolisthesis of C6 anteriorly with respect to C7 (short arrow). (b) Oblique radiograph of cervical spine. Note the well-corticated defects (arrows) at C6 and the grade I spondylolisthesis of C6 anteriorly with respect to C7 (arrowhead). (c) Anteroposterior radiograph of cervical spine. Bilateral spondylosis defects (arrows) are present. Spina bifida occulta (o) can be identified.
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Figure 1b. (a) Lateral radiograph of cervical spine in extension. Note the well-corticated defect (long arrow) between the superior and inferior articular pillars of C6 bilaterally and the grade I spondylolisthesis of C6 anteriorly with respect to C7 (short arrow). (b) Oblique radiograph of cervical spine. Note the well-corticated defects (arrows) at C6 and the grade I spondylolisthesis of C6 anteriorly with respect to C7 (arrowhead). (c) Anteroposterior radiograph of cervical spine. Bilateral spondylosis defects (arrows) are present. Spina bifida occulta (o) can be identified.
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Figure 1c. (a) Lateral radiograph of cervical spine in extension. Note the well-corticated defect (long arrow) between the superior and inferior articular pillars of C6 bilaterally and the grade I spondylolisthesis of C6 anteriorly with respect to C7 (short arrow). (b) Oblique radiograph of cervical spine. Note the well-corticated defects (arrows) at C6 and the grade I spondylolisthesis of C6 anteriorly with respect to C7 (arrowhead). (c) Anteroposterior radiograph of cervical spine. Bilateral spondylosis defects (arrows) are present. Spina bifida occulta (o) can be identified.
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IMAGING FINDINGS
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The most important imaging finding was discontinuity of the superior and inferior articular facets of C6 by a well-corticated cleft (Figs 1, 2). This cleft divided the articular mass into triangular fragments. The separation of the fragments was further compounded by the grade I spondylolisthesis of C6 with respect to C7 (Fig 1a, 1b). Other abnormalities included spina bifida occulta (Figs 1c, 2), hyperplasia of the adjacent articular processes (Fig 1a), dysplastic posterior elements, and medial displacement of the inferior facets and laminae (Fig 2). Soft-tissue swelling was notably absent. The bilateral spondylolysis defects were visible at MR imaging in this case (Fig 3). These findings indicated a diagnosis of bilateral spondylolysis of C6.
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Figure 2. Transverse 3-mm-thick nonenhanced CT image at the level of the pedicle of C6. Note the well-corticated spondylosis defects (arrows), medial displacement of the laminae (L), and spina bifida occulta (o). When this image was reviewed with narrow window settings (not shown), no soft-tissue swelling was present.
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Figure 3. Left lateral sagittal T1-weighted MR image (3 mm thickness; repetition time, 300 msec; echo time, 11 msec; 1.5 T) shows the split left articular pillar connected by a thin band of material (arrow) of low signal intensity, possibly fibrous tissue. High-signal-intensity fat fills the remainder of the gap. The right side (not shown) had the same findings.
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DISCUSSION
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Cervical spondylolysis is defined as a "corticated cleft between the superior and inferior articular facets of the articular pillar, the cervical equivalent of the pars interarticularis in the lumbar spine" (1). It is frequently an incidental finding on studies related to trauma or pain (2). It is much more rare than lumbar spondylolysis. Authors of a review (3) in 1992 found 79 lesions related to cervical spondylolysis in 71 patients reported on in the medical literature, as compared with an estimated 5% of the population harboring lumbar spondylolysis.
The principal imaging modalities used to diagnose cervical spondylolysis are radiography and computed tomography (CT). The imaging findings reported include an articular mass cleft, triangular pillar fragments, hypoplasia of the ipsilateral pedicle, dysplastic ipsilateral laminae, and spina bifida (1,4–6). The cleft is oriented obliquely to the plane of the facet joint, ranging from vertical to perpendicular to the joint. Compensatory hypertrophic changes of the articular process in the adjacent vertebrae and spondylolisthesis are frequently seen (3). The spondylotic cleft and spondylolisthesis give the appearance of posterior displacement of the dorsal pillar, a finding frequently described. The spondylolisthesis is usually grade I and less than 3 mm (7). Magnetic resonance (MR) imaging is infrequently performed and has been reported to be unhelpful for the diagnosis of spondylolysis (1). In one reported case, spondylolysis was not seen (8), but MR imaging has excluded the diagnosis by showing intact articular masses in other cases (7). The bilateral spondylolysis defects were visible at MR imaging in the case in this article (Fig 3). MR imaging is more useful, when clinically necessary, to evaluate the spinal cord, not the osseous anatomy (2).
Twelve patients are discussed in two of the most recent reviews (1,3). They ranged in age from 20 to 81 years at diagnosis. The patients had markedly varied symptoms, ranging from asymptomatic to mild nonspecific neck pain, neck stiffness, and radiculopathy. Most patients with cervical spondylolysis have normal neurologic examination results, although there are exceptions (2,8). Although our findings were bilateral in the case in this article, nine of the 12 patients in the review articles (1,3) had unilateral lesions. The most commonly affected cervical level is C6, followed in frequency by C4 (1). Spondylolysis has not been reported at C1 or C7. All of the 12 patients had spondylolysis at only one level, but simultaneous involvement of two or even three levels has been reported (9). Cervical spondylolysis is more frequently diagnosed in men (nine of 12) (1,3).
Many authors (1,2–5,9) believe spondylolysis is congenital. Since the articular mass forms from one ossification center (4), spondylolysis cannot be due to failure of union of ossification centers but may be due to faulty ossification within one (2). The lack of identification of spondylolysis in the postmortem examination of infants sheds doubt on a congenital cause (4). The associated congenital anomalies may predispose to developing spondylolysis. Although repetitive microtrauma or posttraumatic nonunion are attractive hypotheses, there is no direct evidence to support those theories.
Since the mainstay of treatment is conservative, it is most important to differentiate cervical spondylolysis from an acute fracture, which may require acute surgical intervention (1,3). Surgery is considered when there is instability or when conservative therapy fails (10). The need for surgery to relieve spinal cord compression is rare (2). Irregular unmarginated fracture fragments and soft-tissue swelling (4), typically seen in acute fractures, are not found. Frequently, spondylolysis is misdiagnosed as facet dislocation. Familiarity with spondylolysis will lead to the proper observation that there is not a displacement of an inferior facet relative to a superior facet but in fact a spondylolysis defect dividing one or more articular masses. Differentiation from a chronic fracture can be difficult, but corticated margins and associated congenital anomalies favor spondylolysis (7). Although this distinction can be difficult in children (11), it can still be made with confidence, even in older patients with superimposed acquired abnormalities (Fig 4).
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Figure 4. Bilateral spondylolysis of C6 in a 65-year-old man who complained of a few months of pain along the back of the neck, especially when turning during driving, with no history of recent or remote neck trauma. Lateral cervical spine radiograph shows advanced multilevel disk degeneration and facet arthritis. Note the well-corticated cleft (long arrow) traversing the displaced superior (s) and inferior (i) pillars of C6, almost perpendicular to the plane of the facet. There is also grade I spondylolisthesis (short arrow).
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Our congratulations to the 42 individuals who submitted the most likely diagnosis (bilateral cervical spondylolysis of C6) for Diagnosis Please, Case 36. The names and locations of the individuals, as submitted, are as follows:
- Michael R. Aiello, MD, Saranac Lake, NY
- Albert J. Alter, Madison, Wis
- Ken Baliga, Rockford, Ill
- Michael S. Barry, DC, DACBR, Denver, Colo
- Doug Brown, MD, Durham, NC
- Michael P. Buetow, MD, Okemos, Mich
- Hearns W. Charles, MD, New York, NY
- Anthony M. Cook, MD, Minneapolis, Minn
- M. G. de Baets, MD, Lugano, Switzerland
- Keith D. Epperson, MD, Milwaukee, Wis
- David A. Forsberg, MD, Knoxville, Tenn
- Milton Fuentealba, MD, General Roca, Rio Negro, Argentina
- Ken Goldberg, Northbrook, Ill
- Bhaskar Golla, Rochester, NY
- Walter O. Grauer, MD, Zurich, Switzerland
- Shinichi Kan, MD, Kanagawa, Japan
- Douglas S. Katz, MD, Mineola, NY
- Stephanos Lachanis, MD, Athens, Greece
- Alan Laorr, MD, Eden Prairie, Minn
- Donald R. Lewis, Jr, MD, Huntington, WVa
- Yoji Maetani, MD, Kyoto, Japan
- Jacques Malghem, Brussels, Belgium
- Kathlyn Marsot-Dupuch, Paris, France
- Sergio J. Moguillansky, MD, Cipolletti, Rio Negro, Argentina
- Narendrakumar P. Patel, MD, Newburgh, NY
- Nicola Pelosi, MD, Palmanova, Italy
- Donald B. Price, MD, Mineola, NY
- M. R. Ramakrishnan, MD, Big Stone Gap, Va
- Luiz Antonio Rossi, São Paulo, SP, Brazil
- Lindsay Rowe, MD, Newcastle, Australia
- Pierre Sauvage, MD, Niamey, Niger
- Steven M. Schultz, MD, Fort Worth, Tex
- Pranshu Sharma, Pitam Pura, Delhi, India
- David F. Sobel, La Jolla, Calif
- Dr. Anne Stroh Marcy, Arras, France
- Douglas L. Teich, MD, Brookline, Mass
- Melvin L. Turner, DO, Ardmore, Pa
- Kai Vilanova Busquets, MD, Girona, Spain
- Christopher Vittore, MD, Rockford, Ill
- Terry R. Yochum, DC, DACBR, Denver, Colo
- Stanko Yovichevich, MD, Sydney, Australia
- Joe Yut, Olathe, Kan
There was one individual who submitted the highest number of most likely diagnoses for cases 25–36. The name of this person will be announced in an upcoming issue of the Journal.
In the April 2001 issue, Edward L. Baker, MD, one of the individuals who submitted the most likely diagnosis for Case 33, is from San Francisco, Calif.
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FOOTNOTES
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Part 1 of this case appeared 4 months previously and may contain larger images.
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REFERENCES
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Forsberg DA, Martinez S, Vogler JB, III, Wiener MD. Cervical spondylolysis: imaging findings in 12 patients. AJR Am J Roentgenol 1990; 154:751-755.[Abstract/Free Full Text]
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Charlton OP, Gehweiler JA, Morgan CL, Martinez S, Daffner RH. Spondylolysis and spondylolisthesis of the cervical spine. Skeletal Radiol 1978; 3:79-84.
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Jeyapalan K, Chavda SV. Case report 868. Skeletal Radiol 1994; 23:580-582.[Medline]
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Kan S, Matsubayashi T. Symptomatic cervical spondylolysis. Neuroradiology 1995; 37:559-560.[Medline]
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Yochum TR, Carton JT, Barry MS. Cervical spondylolysis: three levels of simultaneous involvement. J Manipulative Physiol Ther 1995; 18:411-415.[Medline]
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Goupille P, Fouquet B, Cotty P, Valat JP. Cervical spondylolysis (letter). AJR Am J Roentgenol 1991; 157:1127-1128.[Medline]
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Parisi M, Lieberson R, Shatsky S. Hangman’s fracture or primary spondylolysis: a patient and a brief review. Pediatr Radiol 1991; 21:367-368.[CrossRef][Medline]
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HISTORY
IMAGING FINDINGS
