0:01

I did want to end the spinal segment of the emergency neuroradiology clinical

0:09

scenario with a few other entities. I had mentioned Grisel syndrome as you

0:14

recall previously when I was talking about torticollis rotatory subluxation,

0:20

as well as C1 C2 of atlantoaxial subluxation. Grisel syndrome is secondary

0:27

to an inflammatory process of the pharynx occasionally of the middle ear,

0:30

often involving the retropharyngeal space. And this results in a ligamentous

0:36

laxity that occurs between the C1 and C2 vertebrae. You notice that in

0:40

this example, the patient's space between the odontoid process and the C1

0:46

arches is widened on the left side compared with the right side.

0:50

And this is secondary to this ligamentous laxity that allows torticollis

0:56

to occur. This is some thickening here of the retropharyngeal space.

1:01

Here, you see a different case in which there is rotation of C1

1:06

with respect to the skull base as well as the C2 odontoid process,

1:11

yet another example of Grisel syndrome with torticollis as the presentation.

1:17

Grisel syndrome should not be concerned with another case that we see in

1:21

the emergency department quite frequently and that is calcific tendonitis

1:25

of the longus colli musculature. This is also a case that is very

1:29

frequently shown in boards, as well as in

1:34

maintenance of certification. What one sees is calcification that is embedded

1:40

in the longus colli, longus capitis muscle complex, which is associated

1:45

with retropharyngeal edema. So on the CT scan, we see this retropharyngeal

1:52

space edema as well as the calcification. On the sagittal scan you see

1:57

the edema in low density extending from the calcification all the way down

2:02

to the C5 level with increased space in the interior soft tissues,

2:08

interior to the vertebral bodies. On MR, bright signal intensity from the

2:13

inflammatory process, as well as the low signal intensity of the calcifications

2:18

and you may even see some areas of contrast enhancement in the prevertebral

2:23

musculature, the longus colli, longus capitis muscle complex.

2:27

The importance of this is to recognize that this is not due to

2:32

spinal pathology and an abscess, it's due to the longus colli tendonitis.

2:39

This is treated with nonsteroidal anti inflammatory drugs with response

2:44

in days to weeks, as opposed to an infectious etiology where one would

2:49

require intravenous antibiotics. So no antibiotics necessary, non steroidal

2:55

anti inflammatory drugs and this will resolve over the course of a week.

3:00

I mentioned the entity of Guillain Barré syndrome. You can see in this

3:04

case the diffuse enhancement of the nerve roots

3:08

at the cauda equina, extending onto the surface of the conus medullaris.

3:13

Guillain Barré does not generally show the enhancement in the cord itself.

3:20

This is kind of an autoimmune reaction to the pathogens that are circulating

3:27

in the system and it's an autoimmune reaction unfortunately to the cauda

3:31

equina and nerve roots most commonly. You can occasionally see this in the

3:35

cervical spine nerve roots, much less common than in the lumbar spine nerve

3:39

roots. The differential diagnosis when one has these spinal pathologies

3:44

includes this case. This is a child who has a soft tissue mass

3:49

anterior to the thoracolumbar junction with extension into the paraspinal

3:55

soft tissues. On the axial scan, you see a large mass,

3:59

which is extending into the neural foramen and displacing the spinal cord

4:04

to the left side. With administration of gadolinium, you see the enhancing

4:08

mass as well as the epidural component to this mass. This is not

4:13

an inflammatory process. Were this an inflammatory process, we'd likely

4:17

see with the size of it, some element of necrosis associated with this.

4:22

This is a patient who has a neuroblastoma and in a child it is in

4:27

our differential diagnosis for paraspinal soft tissue inflammation. So this

4:32

is one of the most common of the congenital malignancies. It represents

4:36

30% of all fetal tumors. It's derived from neural crest cells that originate

4:41

from the sympathetic nervous system plexus. You know that with increasing

4:45

age, this converts from neuroblastoma to ganglioneuroblastoma to a ganglioneuroma

4:52

and ganglioneuromas are relatively benign in their course.

4:56

The survival rate is very high and it does respond quite readily to

5:01

chemotherapy.