Spine Anomalies

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0TH fr Volume 8, Number 3 #{149} May, 1988 #{149} RadioGraphlcs 455 RadloGraphics index terms: Musculoskeletai Imaging SPINE Cumulative Index terms: Spine, abnormalities The vertebral body: Radiographic configurations in various congenital and acquired disorders Rajendra Kumar, M.D.’ Faustino C. Guinto, Jr., M.D.’ John E. Madewell, M.D.t Leonard E. Swischuk, M.D.’ Ruppert David, M.D.t THIS EXHIBIT WAS DISPLAYED AT THE 73RD SCIENTIFIC ASSEMBLY AND ANNUAL MEETING OF THE RA- DIOLOGICAL SOCIETY OF NORTH AMERICA. NOVEMBER 29-DECEM- BER 4. 1987. CHICAGO. ILLINOIS. IT WAS RECOMMENDED BY THE MUS- CULOSKELETAL AND PEDIATRIC IM- AGING PANELS AND WAS AC- CEPTED FOR PUBLICATION AFTER PEER REVIEW ON MARCH 7. 1988. From the Departments of Radiology, University of Texas Medical Branch, Galveston (a), and Baylor College of Medicine (t), Houston, Texas. Address reprint requests to P. Kumar, M.D., Depart- ment of Radiology, University of Texas Medical Branch, Gal- veston, TX 77550. InuI7 III’.lI VI I 1 WJlIW .tlons are disease- specific and when recognized on radiographs, make correct diagnosis possible. Introduction A normal vertebra has a body (centrum) and posterior elements. The body has a distinct shape and appears rectangular on radiographs. Its height tends to be somewhat less than its width. Many intrinsic and extrinsic disease processes may alter this normal vertebral body configuration. Such disorders may be congenital or acquired, often imparting specific shapes to the body (Table I). A knowledge of such abnormal vertebral body configurations may aid in the diagnosis of an underlying disorder. The body of a vertebra is composed of canceilous tissue covered by a thin layer of compact bone, and contains numerous blood vessels. The trabeculae of the vertebra are more pronounced in the vertical than in the horizontal direction in response to greater stress along the cephalocaudal axis. Slight concavity normally characterizes all the surfaces of the vertebral body.

Transcript of Spine Anomalies

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Volume 8, Number 3 #{149}May, 1988 #{149}RadioGraphlcs 455

RadloGraphics index terms:Musculoskeletai Imaging

SPINE

Cumulative Index terms:Spine, abnormalities

The vertebral body:Radiographic configurationsin various congenital andacquired disorders

Rajendra Kumar, M.D.’

Faustino C. Guinto, Jr., M.D.’

John E. Madewell, M.D.t

Leonard E. Swischuk, M.D.’

Ruppert David, M.D.t

THIS EXHIBIT WAS DISPLAYED ATTHE 73RD SCIENTIFIC ASSEMBLYAND ANNUAL MEETING OF THE RA-DIOLOGICAL SOCIETY OF NORTHAMERICA. NOVEMBER 29-DECEM-BER 4. 1987. CHICAGO. ILLINOIS. ITWAS RECOMMENDED BY THE MUS-CULOSKELETAL AND PEDIATRIC IM-AGING PANELS AND WAS AC-CEPTED FOR PUBLICATION AFTERPEER REVIEW ON MARCH 7. 1988.

From the Departments of

Radiology, University of TexasMedical Branch, Galveston

(a), and Baylor College ofMedicine (t), Houston, Texas.

Address reprint requeststo P. Kumar, M.D., Depart-ment of Radiology, Universityof Texas Medical Branch, Gal-veston, TX 77550.

In�uI7 � III’.lI V�I I � �1 �WJlI�W �.tlons are disease-specific and when recognized on radiographs, makecorrect diagnosis possible.

Introduction

A normal vertebra has a body (centrum) and posterior elements.The body has a distinct shape and appears rectangular onradiographs. Its height tends to be somewhat less than its width.Many intrinsic and extrinsic disease processes may alter this normalvertebral body configuration. Such disorders may be congenital oracquired, often imparting specific shapes to the body (Table I). Aknowledge of such abnormal vertebral body configurations may aidin the diagnosis of an underlying disorder.

The body of a vertebra is composed of canceilous tissuecovered by a thin layer of compact bone, and contains numerousblood vessels. The trabeculae of the vertebra are more pronouncedin the vertical than in the horizontal direction in response to greaterstress along the cephalocaudal axis. Slight concavity normallycharacterizes all the surfaces of the vertebral body.

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Figure 1Schematic drawing depicting the development ofnormal and abnormal vertebral bodies.

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Table IClassification of the Abnormal

Configurations of the Body of a Vertebra

Congenital Acquired

A. Asomia (agenesis) A. Abnormal sizeB. Hemiventebra 1 . Small vertebral bodyC. Coronal cleft 2. Enlarged vertebral bodyD. Butterfly vertebra B. Bonder abnormalitiesE. Block vertebra 1. Anterior border scallopingF. Hypoplasia

C.

D.

2. Posterior border scalloping3. Lateral border scalloping4. Anterior border straightening

5. Endplate deformitiesVertebral tongues, spurs and beaks

Miscellaneous body shapes

Embryologic Considerations

The body of a vertebra develops from thecells of the sclenotome, a derivative of the no-tochord. Two ossification centers, one for theventral and the other for the dorsal half of thebody, appear by the 9th gestational week. Os-sification of these centers is complete by the12th week. These centers soon fuse to form asingle large center which later divides thebody of the future vertebra into two thickplates where endochondral ossification oc-

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curs. The portions of the notochord inconporat-ed within the body undergo atrophy and dis-appear. Those which lie within the intenverte-bral discs enlarge and persist as the nucleipulposi.

Any deviation in the normal developmentof the body of a vertebra leads to many con-genital anomalies in its configuration, as illus-trated in Figure 1.

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Figure 2 Figure 3Asomia Congenital absence of the body of Left hemivertebra involving Ti 1L2 Hypoplastic posterior elements are present (an-now).

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Vertebral Body ConfigurationsCongenital

Developmental deformity of the body of a vertebra is oftenassociated with congenital anomalies of the genitouninany,gastrointestinal, and central nervous systems.

A. Asomia (A genesis)

Complete absence of the body of a verte-bra may occur despite the presence of theposterior elements (Figure 2). This anomaly ne-suIts from failure of ossification centers of thebody to appear. One on more vertebral seg-ments may be involved.

B. Hemivertebra

Unilateral wedge vertebra is due to lack ofossification of one-half of the body. A right onleft hemivertebra may thus occur. The hemiver-tebra assumes a wedge-shaped configurationwith the apex of the wedge reaching the mid-plane (Figure 3). Scoliosis is often present atbirth.

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�& t:��’ �Figure 4Dorsal hemivertebra involving Li Metametric hemivertebrae in the lower lumbar spine

with “mermaid” deformity of the lower extremities.

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Dorsal and ventral hemivertebrae occurbecause of failure of the ventral or dorsal halfof the vertebral body to ossify (Figure 4). Thefailure of ossification is believed to be second-any to ischemia during the developmental stage.A kyphotic defonmity is seen at the site of adorsal hemivertebra. A ventral hemivertebra isextremely rare and results from failure of ossifi-cation of the dorsal half of the vertebral body.

Hemivertebra secondary to hemimetame-tric segmental displacement or persistence ofthe night and left halves of the vertebral bodyleads to the hemiventebnae being separatedfrom each other in the sagittal plane. One suchhemivertebra may fuse with the body of a yen-tebnal segment above or below the affectedsegment (Figure 5).

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Figure 6Vertebrae with coronal clefts are seen on this later- Figure 7al view of the thonacolumban spine. “Butterfly” vertebra involving L4

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C. Coronal Cleft

This anomaly results from a failure of fusionof the anterior and posterior ossification cen-tens which remain separated by a cartilageplate. It represents a delay in normal vertebralmaturation; in most cases clefts disappear bysix months after birth. Coronal clefts are usuallyseen in the lower thonacic on lumbar vertebralbodies. The deformity is most often seen in pre-mature male infants and can be recognized inutero. Cleft vertebrae may also occur in infantswith chondrodystrophia calcificans congenita.Radiognaphically, a vertical radiolucent band isseen just behind the midportion of the body onthe latenial view of the spine (Figure 6).

D. Butterfly Vertebra(Sagittal Cleft Vertebra)

Butterfly vertebrae result from the failure offusion of the lateral halves of the vertebralbody because of persistent notochondal tissuebetween them. The involved vertebral body iswidened, and the bodies above and below thebutterfly vertebra adapt to the altered inter-vertebral discs on either side by showing con-cavities along the adjacent endplates (Figure7). Some bone bridging may occur across thedefect which is usually seen in the thoracic onlumbar segments of the spine. Anterior spinabifida, with on without anterior meninogocele,may be associated with a butterfly vertebra.

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Figure 8(A) Block vertebra with congenital fusion of C4 andCS Note the presence of a “waist” at the site offusion (arrow). (B) Acquired vertebral body fusionof CS and C6.

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E. Block Vertebra(Congenital Vertebral Fusion)

This congenital abnormality is due to a fail-ure in the process of segmentation during fetallife. The fusion may be complete (both anteriorand posterior elements involved), or partial.The height of fused bodies equals the sum ofthe heights of the involved bodies and the in-tervertebral discs between them. In acquired

vertebral fusion, this dimension is less than in thecase of congenital fusion. A “waist” is oftenseen at the level of the intervertebral disc be-tween the fused segments (Figure 8A). Thisfinding is usually absent in an acquired verte-bral fusion (Figure 8B). The intervertebral fonam-ma of block vertebrae become ovoid and nar-rowed. Congenital vertebral fusion usuallyoccurs in the lumbar and cervical segments.

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Congenital hypoplastic L4 vertebral body

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F. Hypoplastic Vertebra

This anomaly is usually the result of vascular insufficiency duringfetal life. It may affect one on more vertebrae (Figure 9).

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Figure 10The left sided hypoplasia of the vertebral bodiesseen here is due to unilateral irradiation of the lum-bar spine for retnopenitoneal hemangioma duringchildhood. Note the hypoplastic left kidney.

Figure 1 1Juvenile rheumatoid arthritis with hypoplastic cenvi-cal vertebral bodies Note the posterior vertebral fu-sion.

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Vertebral Body ConfigurationsAcquired

Vertebral body abnormalities resulting from trauma, infection,and neoplasm are excluded from this discussion.

A. ABNORMAL SIZE

An abnormality in the size of a vertebra ismost often due to a compression deformity ofthe body. Certain diseases, however, may af-fect the normal vertebral growth resulting in al-tened size.

1. Small Vertebral Body

Radiation-induced vertebral hypoplasiamay result from irradiation of the spine duringearly childhood (Figure 10). The effect is dose-

dependent and, in general, does not occurwith doses of less than 1000 rads. Unilateral radi-ation may cause scoliosis because of unequalgrowth of the affected bodies, the concavityof the scoliosis occurring on the irradiated side.Osteoporosis and vertebral collapse may beseen in adults following irradiation.

Juvenile rheumatoid arthritis causes re-duced vertebral growth because of early epi-physeal closure; this results in small vertebrae(Figure 1 1). Vertebral fusion may also occur.The cenvical spine is most often involved, andatlantoaxial subluxation may be present.

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Figure 13Gaucher’s disease with osteoporosis and compres-sion deformities of vertebral bodies

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Eosinophilic granuloma causes a markedcompression deformity, and may lead to a“vertebra plana” deformity (Figure 12). Lessercompression deformities are more frequent,however. The lumbar and lower thoracic par-tions of the spine are most often involved. This isa self-limiting disease. The vertebra may regain“normal” shape after many years, with or with-out treatment.

Gaucher’s disease is characterized by thedeposit of glucocerebrosides within the neticu-loendothelial cells of the vertebral body. Thiscauses weakening and compression deformitysimilar to that seen in osteoporosis (Figure 13).

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Figure 15Figure 14 Osteogenesis imperfecta tarda with osteoporosisPlatyspondyly in spondyloepiphyseal dysplasia tanda and compression deformities of vertebral bodies

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Platyspondyly generalizata is a nonspecificdescriptive term applied to the many heredi-tary systemic diseases that are associated withflattened vertebral bodies. Though vertebralbodies are flat, the discs tend to be of normalheight. Dwarfism and numerous spinal curva-tune deformities may be present. Such flat yen-

tebral bodies have been described in achon-droplasia, spondyloepiphyseal dysplasia tarda(Figure 14), mucopolysacchanidosis, osteope-trosis, neurofibromatosis, osteogenesis imper-fecta (Figure 15), and many others.

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Thanatophoric dwarfism results in extremeflattening of the hypoplastic vertebral bodies(Figure bA). An “H” on “U” configuration of thevertebral bodies is seen in the anteropostenionview (Figure loB).

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Figure 19Myositis ossificans progressiva with “tallbut slim” vertebrae in the cervical spineNote the ossification of the ligamentumnuchae (arrowhead).

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2. Enlarged Vertebral Body

Paget’s disease causes enlargement of thevertebral body in all dimensions unless compli-cated by a compression fracture. A “picture-frame” appearance may be imparted to thebody in the mixed phase of the disease (Figure17). The body alone on the entire vertebra maybe involved and often appears sclerotic.

Gigantism may cause an increase in theheight of vertebral bodies (Figure 18). The inter-vertebral discs may show a similar change.

Myositis ossificans progressiva producesvertebral bodies that are tall, being greaten inheight than in width (Figure 19). Associated os-teoponosis may ultimately lead to compressiondeformity of the vertebral bodies.

Figure 17Paget’s disease showing enlargement of the L3 yen-tebnal body with the “picture-frame” vertebra ap-peanance

Figure 18Gigantism with “tall” vertebral bodies in the cervicalspine

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B. BORDER ABNORMALITIES

Any border of a vertebral body, including the end plates, may be affected.

1. Anterior Border Scalloping cent vertebral body (Figures 20A and B). Thedefect has a sclerotic margin, consistent with

Aortic aneurysm because of its pulsatile the chronicity of the process. The lower thonac-pressure may cause a concave compression ic and upper lumbar vertebral segments aredefect along the anterior surface of an adja- most often involved.

Figure 20(A) This lateral tomognam of the lumbar spine shows anterior verte-bnal notching (arrows) of L2 and L3. (B) A CT section through L3shows that the anterior vertebral notching is caused by a large ab-dominal aortic aneurysm. Note the contrast enhanced lumen of the en-langed aorta in the center and the calcification in the wall of the aneu-rysm. (Courtesy of N. Patel, M.D., Newburgh, NY.)

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Figure 21Normal posterior vertebralnotching in the lumbar spine

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2. Posterior Border Scalloping

Normal posterior scalloping may occur asa rare variant. In contrast to the concave de-fect seen with other disorders, the posteriorscalloping that represents a normal variant ischaracterized by an angular defect with itsapex pointing anteriorly (Figure 21).

Neurofibroma tosis is assoc iated withmarked scalloping of the posterior bonders ofthe vertebral bodies caused by dunal ectasia onintnaspinal tumors (Figures 22A and B). Widen-ing of the intervertebral fonamina may be seen.Any spinal segment may be involved, and scoli-osis and kyphoscoliosis may be present. Rarely,anterior bonder scalloping may be seen in neun-ofibromatosis.

Figure 22(A) Neurofibromatosis with posterior vertebralnotching in the lumbar spine (B) A myelognamshows that the vertebral notching is secondary todural ectasia.

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Figure 23Achondroplasla with posterior vertebral notching inthe thonacolumbar spine

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In achondroplasia, posterior indentation ofthe vertebral bodies may be present owing to adevelopmental defect (Figure 23). Platyspon-dyly is often seen. Disc henniations with markedspondylosis defonmans are frequently seen inolden patients.

In acromegaly, scalloping is often presentalong the posterior aspect of lumbar vertebrae(Figure 24), and the antenopostenior diameterof the bodies may be increased in the thonacicspine. Diffuse osteoporosis is common withcompression deformities of the vertebral bod-ies. Marked spondylosis defonmans may bepresent.

Figure 24Acromegaly with posterior vertebral notching in thelumbar spine

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Figure 25Ependymoma with posterior vertebral notching inlumbar vertebral bodies (“Dog spine”)

Figure 26Meningocele with posterior vertebral notching in themid thonacic spine (arrows)

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Ependymoma (‘Dog Spine”) usually onigi-nates in the filum terminale and produces scal-loping along the posterior borders of lumbarvertebral bodies (Figure 25). Rarely, the lowerthoracic vertebrae may be involved. There isalso widening of the spinal canal with thinningand spreading of the vertebral pedicles (anylarge intraspinal tumor on dural ectasia canproduce similar defects).

Posterior meningocele (Spina bifida cys-tica) most often occurs in the lumbar and sa-cral regions. Posterior concave vertebral inden-tations occur as a result of compression by themeningocele (Figure 26). Widening of the spi-nal canal with spreading and thinning of verte-bral pedicles is also seen, and spina bifida andother congenital vertebral anomalies are oftenpresent. Both posterior and anterior meningo-celes may occur in neurofibromatosis.

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Figure 28Ankylosing spondyiltis with straightening of the an-tenon bonders of the lumbar vertebral bodies

Figure 27Neurofibromatosis Vertebral notching caused byneunofibnomas is seen along the night lateral bondersin the thonacic spine.

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3. Lateral Border Scalloping

Any benign mass that lies in close proximityto either side of the vertebral column maycause indentations along the lateral bonders ofvertebral bodies. This may be seen in neurofi-bromatosis, for example (Figure 27).

4. Anterior Border Straightening

Ankylosing spondylitis produces a “square”on “box-like’ ‘ vertebral body configuration inthe early stages of the disease, owing tostraightening of the anterior border (Figure 28).This, in turn, is the result of bone erosions at theanterior corners of the body resulting in loss ofthe normal concavity of the anterior vertebralsurface. This finding is best seen in the lumbarspine.

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5. Endplate Abnormalities

Osteoporosis occurs in many disorders andresults in weakening and collapse of the vente-bral body. It is often seen in postmenopausalwomen. Compression deformity of one on morevertebral bodies may occur with decrease inthe vertebral height, and ultimately wedge-shaped, flat on biconcave vertebral bodies(“fish vertebra”) may result (Figures 29A and B).

Figure 29Osteoporosis (A) “Fish-vertebrae” with biconcavedeformities of lumbar vertebral bodies (B) Normalspine of a fish showing biconcave vertebrae

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Figure 30Steroid induced osteoporosis with vertebral com-pression deformities Note the increased sclerosissubjacent to the deformed superior endplates.

Figure 31Sickle cell anemia with “step-off” deformity of yen-tebral endplates (“H” vertebra) in the thoracicspine

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Steroid-induced osteoporosis occurring inpatients who have Cushing’s syndrome or whoare on exogenous steroid therapy is a general-ized process. In the spine, compressed verte-bral bodies resulting from the osteoporosis mayshow bone condensation along the superiorand inferior endplates (Figure 30), a feature in-frequently seen with compressed osteoporoticvertebrae resulting from other causes.

Sickle cell disease causes a step-like cen-tral depression of the vertebral endplates thatresults in the appearance of an “H vertebra”(Figure 31). Compression of the central portionsof the endplates occurs because of subchon-dral bone infancts in the vertebral body. Thebody, because of infarction, is usually nonho-mogeneous in appearance. The integrity of theperipheral endplates is believed to be pre-served by a collateral blood supply. The discspaces may be narrowed. Similar step deformi-ties may also be seen in mixed hemoglobinopa-thies.

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The vertebral body: Acquired and congenital disorders Kumar et al.

A Schmorl’s node is a contour defect in the end-plate of a vertebra resulting from central herni-ation of a portion of the disc into the adjacentvertebral body (Figures 32A and B). A defect orweakness in the endplate leads to such dischenniation. A Schmorl’s node is seen as a radio-lucent defect with a sclerotic margin subjacentto the vertebral endplate.

Figure 32(A) Schmorl’s nodes deforming lumbar vertebralendplates (B) This photomicrograph shows cen-tnal herniation of the nucleus pulposus into the ad-joining vertebra, resulting in a Schmorl’s node for-motion. D = disc; N nucleus pulposus; Vvertebral body

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A limbus vertebra represents a distinct typeof disc henniation in which there is intnaosseouspenetration of disc material at the junction ofthe endplate with the vertical bony rim of avertebral body. An oblique nadiolucent defectis seen coursing toward the outer surface of thevertebral body which separates a small seg-ment of the bone (Figure 33). It most often oc-curs at the antenosupenion corner of a singlelumbar vertebra.

A “ring” epiphysis is a cartilaginous ringaround the superior and inferior margins of avertebral body. They represent a normal as-pect of the development of a vertebra, andare seen as small, step-like recesses at the con-ners of the anterior edges of vertebral bodies inpatients 6 to 9 years of age (Figure 34). Later,the entire ring may calcify. The fusion of the ringepiphyses to the vertebral body is complete by12 years of age.

Figure 33Limbus vertebra Note the nadiolucent defect at theanterosupenion bonder of L4 (arrow).

Figure 34Normal “ring” eplphyses of the thonacic and lumbarvertebral bodies

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pearance of the lumbar spine lumbar spine

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Renal osteodystrophy is characterized bythe presence of horizontal bands of increasedopacity subjacent to the endplates of vente-brae. These zones of sclerosis alternate wIth ra-diolucent bands through the centers of the yen-tebral bodies and the radiolucent disc spaces,imparting a “nuggen-jensey” appearance to

the spine. The sclerotic bands are believed tobe due to condensation of excessive osteoidadjacent to the endplates. The “nugger-jer-sey” appearance is usually seen in renal osteo-dystrophy (Figure 35), but may occur in osteo-petnosis (Figure 30) and myelofibnosis.

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In Hurler’s syndrome (Gargoylism), verte-bral bodies have a rounded appearance. Amild kyphotic curve is seen at the thoracolum-ban junction. The body at the apex of the ky-photic curve is somewhat smaller than theadjacent bodies and is deficient in its antero-superior aspect. As a result, its lower half pro-jects anteriorly in a tongue-like fashion (Figure38). Usually, it is the body of T12, LI or L2 that isinvolved. Similar but less severe changes areoften seen in Hunter’s syndrome.

Figure 38Hurler’s syndrome with “step-off” deformities alongthe anterior margins of the lumbar vertebral bodies

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In osteopetrosis, sclerotic vertebral end-plates alternate with the radiolucent regions ofthe disc spaces and the midportions of the yen-tebnal bodies, producing a “sandwich” verte-bra on “hamburger” vertebra appearance inchildren (Figure 37). A “ruggen-jensey” spinemay be seen in adults (Figure 36).

C. VERTEBRAL TONGUES, BEAKS AND SPURS

Various bony projections may arise alongthe vertebral margins. Some of these projec-tions impart specific contours to vertebral bod-ies.

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Figure 39Morqulo’s disease with cen-tral beaking along the anteni-or margins of the thoraco-lumbar vertebral bodies

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In Morquio’s disease, the vertebral bodiesare markedly flattened and widened and an-tenor “tongue-like” elongations of their cen-tral portions are seen (Figure 39). The endplatesof the bodies are coarse and irregular. Discspaces may appear normal or somewhat wid-ened. Usually the entire vertebral column is in-volved, and a kyphoscoliosis may be present.

In hypothyroidism, the vertebral bodiestend to be small and flat. Anterior “tongue-like” deformities of the vertebral bodies arepresent in children (Figure 40A). The discspaces are widened and the endplates maybe irregular. With treatment, most vertebralchanges tend to disappear, and only minor ne-sidual deformity of the vertebral bodies re-mains in the adult (Figure 40B).

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Spondylosis deformans represents degen-enative disc disease and is most often seen inolden persons. Osteophytes occur as a result ofthe shearing of the outer annular (Sharpey’s) fi-bers, which connect the annulus fibnosus to theadjacent vertebral bodies. These fibers areruptured with disc henniation which separatesthe overlying anterior and longitudinal spinal

ligaments from the vertebral bodies. Reactivebone formation at these sites of disruption re-suIts in the formation of horizontal and verticalosteophytes. The osteophytes arise along theanterior and lateral aspects of the vertebralbodies (Figures 41A and B). Osteophytes alongthe posterior aspect of the vertebral body arerare.

Figure 41Spondylosis deformans with osteophytosis in theanteropostenior (A) and lateral (B) views

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Figure 42Diffuse idiopathic skeletal hyperostosis involvingthe thoracic spine with ossification of the anteriorlongitudinal ligament

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Diffuse idiopathic skeletal hyperostosis(DISH) (Forestier’s disease) is defined as flow-ing calcification and ossification along the an-terolateral aspects of at least four contiguousthoracic vertebral bodies with or without os-teophytosis (Figure 42). Relative preservationof the disc spaces of the affected vertebrae isoften seen. It most often affects the thoracicspine but may involve any spinal segment.

In ankylosing spondylitis, bilaterally sym-metrical syndesmophytes occur because ofossification of the annulus fibrosus. A “bamboospine” appearance is typically seen as a resultof extensive syndesmophytosis (Figure 43).“Discal ballooning” producing biconvex inter-vertebral discs may be present owing to os-teoponotic deformity of the endplates.Straightening of the anterior margins of verte-bral bodies occurs because of bone erosionsat the anterior corners of the bodies (Figure28). Ossification of panaspinal ligaments is alsoseen.

Figure 43Ankylosing spondylitis with a“bamboo” spine resulting fromsymmetrical syndesmophytosis onan anteropostenior view of the lum-bar spine

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In fluorosis, vertebral osteophytosis and hy-penostosis with sclerotic vertebral bodies areoften seen. Calcification of panaspinal liga-ments may occur, kyphoscoliosis of the spinemay be present, and neurological deficits mayoccur in advanced cases.

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Figure 44Fluorosis Anteropostenior (A) and lateral (B)views of a lumbar spine show ossification of the par-aspinal longitudinal ligaments.

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Figure 46Osteoporosis mimicking vertebral hemangiomas

Note the fine vertical stniations in the lumbar verte-bral bodies.

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D. MISCELLANEOUS CONFIGURATIONS

Hemangioma is most often seen in the low-en thoracic and upper lumbar portions of thespine. Thickening of the vertical bony trabecu-lae in the body produces what has been

called the “accordion” or “corduroy” appear-ance of the involved vertebral body (Figures45A and B). A similar appearance may, attimes, be seen with osteoporosis (Figure 46).One or more vertebrae may be involved.

45BFigure 45(A) Hemangioma involving the T8 vertebral body(B) CT shows that the “honey-comb” appearanceof the body is caused by coarse bone tnabeculae.

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Figure 47“Bone-within-bone” vertebra Antenopostenior (A)and lateral (B) views of the lumbar spine show“stress lines” of unknown cause along the end-plates of the vertebral bodies.

Table iiCauses of Ghost Vertebra

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“Bone-within-bone” vertebra (ghost verte-bra) occurs following a stressful event duringvertebral growth in childhood (Figures 47A andB). Thin transverse lines parallel to the vertebralendplates represent “poststress”, “recovery”,

on “regnowth” phenomena. Once formed, thelines persist throughout life (Figure 48). Variouscauses of the “bone-within-bone” vertebraare listed in Table II.

Stress line RicketsLeukemia ScurvyHeavy metal poisoning HypothyroidismThorotnast injection Hypoparathyroidism

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Figure 48“Bone-within-bone” appearance of lumbarvertebral bodies resulting from Thonotnastadministration The inner, infantile verte-bral body represents vertebral body size at2 years of age when Thorotnast was admin-istered.

The “Napolean hat” sign, seen on an an-teropostenion radiograph, represents a gradeIV spondylolisthesis of L5 over SI (Figures 49Aand B).

Figure 49(A) Spondylolisthesls (Grdde IV) of LS on Si on alateral view (B) The inverted “Napoleonic hat”sign (arrows) on an antenopostenion view of the pel-vis

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Conclusion

The body of a vertebra may assume many differentconfigurations. Some of these contour changes are disease-specific.Recognition of these vertebral body configurations greatly facilitatesradiographic diagnosis.

Suggested Readings

1. Barone BM. Elvidge AR. Ependymomas: A clinical sur-

vey. J Neurosurg 1970; 33:428-438.2. Berens DL. Roentgen features of ankylosing spondylitis.

Clin Orthop 1971; 74:20-33.3. Caffey J. Achondroplasia of the pelvis and lumbosa-

cral spine. Some roentgenographic features. AJR1958; 80:449-457.

4. Compere EL. Johnson WE. Caventry MG. Vertebra pla-na (Calve’ disease) due to eosinophilic gronuloma. JBone Joint Surg (Am) 1954; 36:969-980.

5. Epstein BS. The spine. A radiological text and atlas. 4th

ed. Philadelphia: Lea & Febiger. 1976.6. Gjorup PA. Dorsal hemivertebra. Acta Orthop Scand

1964; 35:117-125.

7. Lang EK. Bessler WT. The roentgenographic features of

acromegaly. AJR 1961 ; 86:321-328.

8. Langer LO. Jr. Spondyloepiphyseal dysplasia tarda: He-reditary chondrodysplasia with characteristic verte-bral configuration in the adult. Radiology 1964;

82:833-839.9. Langer LO Jr. Carey LS. The roentgenographic fea-

tures of the KS mucopolysaccharidosis of Morquio(Morquio-Brailsford Disease). AJR 1966; 97:1-20.

10. Levin EJ. Osteogenesis imperfecta in the adult. AJR1964; 91:973-978.

11. Lonstein JE. Embryology of the spinal cord and verte-bral column. In: Chou SN. Seljeskog EL, eds. Seminars inneurological surgery. Spinal deformities and neurologi-cal dysfunction. New York: Raven, 1978; 1-10.

12. Lott G. Klein E. Osteopetrosis: A case presentation. AJR1965; 94:616-620.

13. Maroteaux P. Lamy M. Hurler’s disease. Morquio’s dis-

ease. and related mucopolysaccharidosis. J Pediatr1965; 67:312-323.

14. Martel W. Holt JF, Cassidy JT. Roentgenologic manifes-tations ofjuvenile rheumatoid arthritis. AJR 1962:

88:400-423.

15. Mitchell GE. Lourie H. Borne AS. The various causes of

scalloped vertebrae with notes on their pathogenesis.Radiology 1967; 89:67-74.

16. Murray RO. Steroids and the skeleton. Radiology 1961;77:729-743.

17. Neuhauser EBD. Wittenborg MH. Berman CZ. Cohen J.Irradiation effects of roentgen therapy on growingspine. Radiology 1952; 59:637-650.

18. Resnick D. Niwayama G. Diagnosis of bone and jointdisorders. Philadelphia: Saunders. 1981.

19. Reynolds J. Pritchard JA, Ludders D. Mason RA. Roent-genographic and clinical appraisal of sickle-cell andbeta-thalassemia disease. AJR 1973; 118:378-400.

20. Rourke JA. Heslin DJ. Gaucher’s disease. AJR 1965;94:621-630.

21. Schmorl G. Junghanns H. The human spine in healthand disease. 2d ed. New York: Grune & Stratton, 1971.

22. Yaghmai I. Spinal changes in neurofibromatosis. Radio-Graphics 1986; 6:26 1-285.