CVJ Abnormality, General

Julia Crim, MD

DIFFERENTIAL DIAGNOSIS

Common

Bone Trauma
- Odontoid Fracture, C2
- Burst Fracture, C2
- Hangman’s Fracture, C2
- Jefferson C1 Fracture
- Occipital Condyle Fracture
- Os Odontoideum
Congenital Neural Abnormalities
- Chiari 1 Malformation
- Chiari 2 Malformation
Congenital Bone and Ligament Abnormalities
- Achondroplasia
- Craniovertebral Junction Variants
- Trisomy 21
- Mucopolysaccharidoses
Arthritis
- Osteoarthritis
- Rheumatoid Arthritis
- Juvenile Idiopathic Arthritis
- Spondyloarthropathy, Seronegative
- CPPD
Soft Tissue Calcification or Ossification
- Calcific Tendinitis, Longus Coli
- Spondyloarthropathy, Seronegative
- OPLL
- CPPD
Extramedullary Mass
- Metastases
- Lymphoma
- Plasmacytoma
- Pannus from Rheumatoid Arthritis
- Abscess, Epidural, Paravertebral
- Osteomyelitis, C1-C2
- Nasopharyngeal Carcinoma
- Neurofibromatosis Type 1
- Schwannoma
- Paraganglioma
- Meningioma
Intramedullary Mass
- Syringomyelia
- Chiari 1 Malformation
- Chiari 2 Malformation
- Hemangioblastoma, Spinal Cord
- Pediatric Brainstem Glioma
Bone Mass
- Metastases
- Multiple Myeloma
- Osteomyelitis, C1-C2
- Chondrosarcoma
- Chordoma (Usually Clivus)
- Aneurysmal Bone Cyst
Cranial Settling, Platybasia and Basilar Invagination, Acquired
- Paget Disease
- Rheumatoid Arthritis, Adult
- Osteomalacia/Rickets

Less Common

Rotary Subluxation, C1-2
Atlanto-Occipital Dislocation
Grisel Syndrome
Carotid Dissection/Pseudoaneurysm

ESSENTIAL INFORMATION

Key Differential Diagnosis Issues

Hint: Differentiate trauma vs. bony congenital variant
- Soft tissue swelling usually evident in trauma
- Cortication of bone indicates nonacute trauma
- Os odontoideum thought to be nonunited fracture, not congenital variant
Hint: Watch for mass adjacent to dens
- Pannus from RA: Dens eroded, no calcification
- Seronegative spondyloarthropathy: Like RA, plus enthesophytes, joint fusion
- Juvenile inflammatory arthropathy: Like adult RA or seronegative spondyloarthropathy
  - Usually involves multiple levels in cervical spine
  - Growth disturbance characteristic
- CPPD: Calcifications, cysts in bone
- Infection: Usually involves disc space
  - Tuberculosis involves disc space later in course of infection
- OPLL, osteoarthritis: No bony erosion
- Tumor: Origin in bone, meninges or cord
Hint: Watch for heterogeneous high signal in bone marrow without cortical breakthrough
- Myeloma
- Lymphoma
- Metastases

Helpful Clues for Common Diagnoses

Types of C2 fractures
- Odontoid Fracture, C2
  - Type I: Obliquely oriented through tip
  - Type II: Horizontally oriented through base
  - Type III: Really a fracture of body; horizontally oriented, through body and below base of dens
- Burst Fracture, C2
  - Axial load injury
  - Extends through posterior cortex of vertebral body
- Hangman’s Fracture, C2
  - Hyperflexion or hyperextension, usually from MVA
  - Traumatic spondylolisthesis of C2
  - Fracture through C2 pedicles
  - Usually see focal kyphosis and anterolisthesis at C2-C3
  - Effendi type I: Traumatic spondylolisthesis isolated
  - Effendi type II: Also disruption of C2-C3 disc
  - Effendi type III: Also disruption of C2-C3 facet joints
- Os Odontoideum
  - Chronic nonunited fracture
Congenital Bone and Ligament Abnormalities
- May be multiple
- May be isolated, detected as incidental finding in adulthood
- Often cause adjacent premature degeneration
Trisomy 21
- Spinal stenosis
- Instability occiput-C1 and C1-C2
- Unlike RA, no erosion of dens
Osteoarthritis
- Common at craniocervical junction
- Involves synovial articulations: Facet joints, dens/C1 articulation
- Dens and anterior arch of C1 develop osteophytes, sclerosis best seen on CT
  
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