The Neck

THE NECK Anna Ben Ely MD Paul Gottlieb MD

Spine 33 vertebræ : • • • • •

Cervical C –7 Thoracic Th –12 Lumbar L – 5 (L1-5) Sacral S -5 (fixed vertebræ) Coccygeal C- 4 (fixed vertebræ)

Vertebra • Body • Posterior part: – vertebral foramen – vertebral or neural arch • consists of 2 pedicles and 2 laminæ • supports 7 processes: 4 articular, 2 transverse,1 spinous

  

Spine intervertebral foramina: • transmit spinal nerves • between transverse processes in cervical region, and in front of them in thoracic and lumbar regions   

Cervical spine • foramen in transverse processes

C1- Atlas • No body • No spinous process • Ring-like: – anterior arch – posterior arch – 2 lateral masses

C2 - Axis • Dens - from the upper surface of the body

C-spine lateral anatomy

C-spine AP anatomy

C Spine open mouth-dens

Examination of cervical spine .1 Cross - table LATERAL: view vertebral 7 • bodies must be seen lines 5 • C1-2 area • Disk spaces • Cervical •

C - spine initial radiograph after diving into a shallow pool

C1 C2 C3 C4 C5

C - spine initial radiograph after diving into a shallow pool with the shoulders lowered C1

C 7 is not visualized -

C2 C3 C4

Dislocation of C5 on C6

C5 C6

the shoulders must be lowered even more

Spine anatomy Swimmer's view

Examination of cervical spine .1 Cross - table LATERAL: view vertebral 7 • bodies must be seen lines 5 • C1-2 area • Disk spaces • Cervical •

‫‪Examination of cervical spine‬‬ ‫קו ‪ - 1‬רקמות הרכות ‪:‬‬ ‫מספר ממ’ בגובה‬ ‫‪C1-3‬‬ ‫ורוחב של פחות‬ ‫מגוף‬ ‫החוליה בגובה ‪C4-‬‬ ‫‪7‬‬ ‫קו ‪ - 2‬גבול הקדמי של‬ ‫החוליות‬ ‫קו ‪ - 3‬גבול האחורי של‬ ‫גופי החוליות‬

‫‪5‬‬

Examination of cervical spine .1 Cross - table LATERAL: view vertebral 7 • bodies must be seen lines 5 • C1-2 area • Disk spaces • Cervical •

Atlanto-Axial relationship

Examination of cervical spine .1 Cross - table LATERAL: view vertebral 7 • bodies must be seen lines 5 • C1-2 area • Disk spaces • Cervical •

Reversal lordosis

C - spine radiograph

• Soft tissue

swelling Anterior gaping

C3

Dislocated de

Examination of cervical spine 2. If LATERAL C - spine view appear normal and if the patient can cooperate FLEXION and EXTENSION views are obtained ) patient makes them without help ! (

C-spine LAT ANATOMY

Flexion

Extension

Examination of cervical spine 3. Anterior view with closed mouth: • lower cervical spine • alignment • oblique fractures

Examination of cervical spine 4. Open-mouth view of dens: • Dens • C1 )inferior and lateral margins ( • C2 )superior and lateral

Examination of cervical spine 5. Oblique views: Neural foramina )C2T1( Articular facets

C spine LAO anatomy

C spine RAO anatomy

C SPINE MRI ANATOMY

C SPINE MRI ANATOMY

ANATOMY

Examination of cervical spine 6. Computed tomography: • Narrow slices • Bone window • MPR

C SPINE CT ANATOMY

C SPINE CT ANATOMY

C SPINE CT ANATOMY

C SPINE CT ANATOMY )CT-myelo(

C1 ‫ חוליה‬- atlas ‫שת הקדמית של‬ C2 ‫ חוליה‬- axis ‫ של‬DE C1 ‫ חוליה‬- atlas ‫של‬Lateral ma

subarachnoid spa spinal co C1 ‫ חוליה‬- atlas ‫שת האחורית של‬

C SPINE CT ANATOMY )CT-myelo(

transverse proces C6 ‫ף החוליה‬ foramen of vertebral arter spinal cor lamin

spinous proces

DD for specific back pain * Degenerative .1 Deformity .2 Inflammatory & infectious .3 Muscular .4 Neoplastic .5 Metabolic .6 Traumatic .7 Psychological .8

• • • • • • • •

Most common *

MAJOR PATHOLOGIC ENTITIES INFECTION: - Osteomyelitis - Diskitis - Epidural abscess - Meningitis - Myelitis - Cord abscess HEMORRHAGE: - Acute epidural hemorrhage - Subacute epidural hemorrhage VASCULAR DISEASE: - Aneurysm, AVM - Hemangioma - Infarction ( arterial, venous )

MAJOR PATHOLOGIC ENTITIES ( cont ) DEMYELINATING DISEASE : - Multiple Sclerosis - Acute Transverse Myelitis - Miscellanious Myelopathies * Radiation * Aids * Compression ( HNP, Tumor ) * Toxic / Metabolic : alcohol, Vit B12, etc

MENINGITIS - 26 y.o. woman, s/p lumbar surgery, low-grade fever, CSF protein/, pleocytosis, no organisms ; diff. thickened, enhanc meninges m/p Aseptic meningitis Note : diffusely thickened, enhanced meninges

T1+ Gad

OSTEOMYELITIS OF THE C - SPINE - Etiopathog : Staphylococcus A.

Trauma of Spine • Motor vehicle accident • Falls • Sport injuries

Trauma of Spine Most common: Upper (C1-C2) cervical spine Lower (C5-C7) cervical spine Thoracolumbar junction (T9-L2)

Imaging studies • X-rays • CT -bones fractures • MRI- soft tissues, spinal cord, CSF, neural roots

Radiology of trauma • Always get two radiographs at 90 degrees to each other! • Look for the second fracture!

Trauma of cervical spine

nterior - flexion forces Following hyperextension forces

FRACTURE OF C1 Jefferson’s fracture • Combination or bust fracture of C1 • Vertical compression injury • Unstable • Widened lateral masses of C1 on openmouth odontoid view

FRACTURE OF C1 Jefferson’s fracture

‫שבר של הלסת‬ ‫תחתונה‬

DENS FRACTURE # of all cervical % 10 Hyperflexion injury -Most common through base of dens

DENS FRACTURE

DENS FRACTURE

FRACTURE OF C2 Hangman’s fracture

Posterior elements of the C2 fractured and displaced inferiorly

‫‪FRACTURE OF C2‬‬ ‫‪Hangman’s fracture‬‬ ‫שבר של אלמנטים‬ ‫אחוריים‬ ‫ותזוזה של ‪ C2‬קדימה‬ ‫לעומת ‪C3‬‬

Teardrop fracture Disruption of posterior ligaments and anterior compression of a vertebral body • Hyperflexion • Most severe and unstable injury of the C-spine • Avulsion of antero-inferior corner of cervical vertebral body by anterior ligament

TRAUMA SEVERE BURST FRACTURE WITH POSTERIOR DISLOCATION OF C5 BODY

COMPRESSED FRACTURE OF C6 BODY

Dislocated den

Unstable cervical spine fractures • • • • • • • •

Flexion teardrop fracture Hangman's fracture Dens fracture Jefferson burst fracture Bilateral interfacetal dislocation Extension teardrop fracture Extension-dislocation Extension-fracture-dislocation

Anatomical Considerations •

• •

•

The neck is a cylinder extending from the mandible to the thoracic inlet and from the base of the skull to the scapulae The anterior triangle of the neck is bordered by the SCMs and the mandible The anterior triangle is divided into the suprahyoid and infrahyoid regions by the hyoid bone Clinicians use the following triangles to navigate neck anatomy

Anatomical Considerations • Nasopharynx • Oropharynx • Hypopharynx

Salivary Glands •

Parotid Gland Located on side of face, anterior to mastoid tip and external auditory canal, inferior to zygomatic arch, and superior to the lower border of the angle of the mandible Stenson's duct enters oral cavity through buccal mucosa opposite upper second molar Facial nerve passes through this gland  • Submandibular Gland Beneath floor of the mouth, inferior to mylohyoid muscles and superior to digastric muscle Wharton's duct enters the floor of the mouth near the lingual frenula  • Sublingual Glands  • Minor Salivary Glands

C SPINE CT ANATOMY

CERVICAL ,,MAP,,

ANATOMY

USES OF THYROID U S • EVALUATE SIZE OF THYROID • CHARACTER AND NO. OF LESIONS • DIFFEREATIATE THYROID FROM EXTRATHYROID MASSES • FOLLOW-UP AFTER THERAPY • MONITOR PATIENTS WITH RISK OF CANCER • US -GUIDED FNA

ADVANTAGES OF THYROID US • • • • • • •

VERY HIGH RESOLUTION [1mm] RAPID PROCEDURE NO IONIZING RADIATION NO PREPARATION NON INVASIVE LOW COST [=SCINTIGRAPHY] IMAGE ADJACENT STRUCTURES

LIMITATIONS OF THYROID US • • • •

OPERATOR DEPENDENT 7-10 MHz TRANSDUCERS MEDIASTINAL AREA NOT SEEN RETROTRACHEAL AREA NOT SEEN

CONGENITAL THYROID ABNORMALITYS • AGENESIS • HYPOPLASIA • ECTOPIA

NODULAR THYROID DISEASE • HYPERPLASIA AND GOITER • ADENOMA • CARCINOMA:               PAPILLARY               FOLLICULAR              MEDULLARY              ANAPLASTIC

• LYMPHOMA

DIFFUSE THYROID DISEASE • • • • •

ACUTE SUPPURATIVE THYROIDITIS SUBACUTE THYROIDITIS HASHIMOTO (CHRONIC LIMPHATIC) GRAVES’ DISEASE DIFFUSE GOITER

DIFFUSE THYROID DISEASE US • • • •

NON-SPECIFIC FINDINGS > SIZE OF GLAND HYPOECHOGENIC TEXTURE > CERVICAL LYMPH NODFS

HASHIMOTO THYROIDITIS

MULTINODULAR GOITER

DIFFUSE GOITER

THYROID NODULE • • • • •

4-7% -PALPABLE NODULE 40% -NODULE ON US 50% -NODULE AT AUTOPSY F > M > AFTER RADIATION

BENIGN FEATURES OF THYROID NODULES • WELL MARGINATED • MOSTLY CYSTIC+- INTERNAL DEBRIS • HYPERECHOGENIC[96% BENIGN] • PERIPHERAL EGG-SHELL CALCIFICATION • THIN HALO

ADENOMA

BENIGN CALCIFICATION

COARSE PERIFERAL

EGG-SHELL

MALIGNANT FEATURE OF THYROID NODULS • • • •

SOLID HYPOECHOIC IRREGULAR MARGINS FINE,PUNCTATE,INTERNAL CALCIFICATIONS

MEDULLARY CA • 5% • HORMON  CALCITONIN

• 20% FAMILAL • COMPONENT OF MEN 2

MICROCALCIFICATION

US DOES NOT RELIABLY DIFFERENTIATE MALIGNANT FROM BENIGN LESIONS

FNA

Lymph nodes • Typical ultrasonographic appearance of a benign hyperplastic lymph node. •

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