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Torticolis Odt
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Literature review current through: Sep 2018. | This topic last updated: Oct 22, 2018.
Lateral views of the cervical spine in two individuals with DISH. The
disc height is well preserved in both. The individual with more
extensive involvement (right panel) complained of mild dysphagia.
DISH: diffuse idiopathic skeletal hyperostosis.
Courtesy of John Esdaile, MD.
Graphic 75500 Version 3.0
Trigger points
Palpation and zones
of a trigger of (black
point reference are
dots) in also present
patients withposteriorly
the
in patients with
myofascial pain the myofascial
syndrome may pain
causesyndrome.
pain at a distant point. This
Reproduced with permission
zone of reference (gray area)from Sheon,
is usually RP, characteristic
quite Moskowitz, RW, for
Goldberg, VM. Soft
each trigger point. Tissue Rheumatic Pain: Recognition,
Schematic
Management, representation
Prevention, of
3rdtheed,cervical
Williamsand T1 dermatomes.
& Wilkins, Baltimore There is no C1
Reproduced with permission from Sheon, RP, Moskowitz, RW,
dermatome. Patients with nerve root syndromes may have pain, paresthesias,
1996.
Goldberg, VM. Soft Tissue Rheumatic Pain: Recognition,
and diminished sensation in the dermatome of the nerve that is involved.
Graphic 79295 Version
Management, 1.0 3rd ed, Williams & Wilkins, Baltimore
Prevention,
Graphic 53006 Version 3.0
1996.
classification criteria
Graphic 66839 Version 1.0
for DISH
Criteria of Resnick and Niwayama
1. The presence of flowing calcification and ossification along the anterolateral aspect of at least
four contiguous vertebral bodies with or without associated localized pointed excrescences at the
intervening vertebral body-intervertebral disc junctions.
2. The presence of relative preservation of intervertebral disc height in the involved vertebral
segment and the absence of extensive radiographic changes of "degenerative" disc disease,
including vacuum phenomena and vertebral body marginal sclerosis.
3. The absence of apophyseal joint bony ankylosis and sacroiliac joint erosion, sclerosis, or
intraarticular osseous fusion.
Criteria of Utsinger
1. Continuous ossification along the anterolateral aspect of at least four contiguous vertebral
bodies, primarily in the thoracolumbar spine. Ossification begins as a fine, ribbon-like wave of
bone but commonly develops into a broad, bumpy, buttress-like band of bone.
2. Continuous ossification along the anterolateral aspect of at least two contiguous vertebral
bodies.
3. Symmetrical and peripheral enthesopathy involving the posterior heel, superior patella, or
olecranon, with the entheseal new bone having a well-defined cortical margin.
Exclusions:
i) Abnormal disc space height in the involved areas
ii) Apophyseal joint ankylosis
Categories of DISH according to the Utsinger criteria are:
Definite = criterion 1
Probable = criteria 2 and 3
DISH: diffuse idiopathic skeletal hyperostosis.
Data from: Resnick D, Niwayama G. Radiographic and pathologic features of spinal
involvement in diffuse idiopathic skeletal hyperostosis (DISH). Radiology 1976;119:559;
and Utsinger PD. Diffuse idiopathic skeletal hyperostosis. Clin Rheum Dis 1985; 11:325.
Graphic 60298 Version 6.0
MRI of cervical spondylitic myelopathy Important causes of
spinal cord
dysfunction*
Clini
Co Dia
Ag cal
urs gno
e featu
e sis
res
Mode
rate-
sever
e
Cer cases
vic Pro demo
al Us gres nstrat
spo ual sive e gait MRI
nd ly or and cerv
ylo >6 step leg ical
tic 0 wis spasti spin
my yea e city e
elo rs cou and
pat rse amyo
Cervical spondylitic myelopathy. Sagittal T2-weighted MRI of the hy troph
cervical spine shows spinal canal narrowing due to disc- y of
osteophyte complexes indenting the ventral aspect of the spinal hand
cord (arrows) and abnormal T2 hyperintense cord signal or
(arrowhead) confirming the diagnosis of myelopathy.
arms
MRI: magnetic resonance imaging.
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Tra
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nsv Segm
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ers Sub ental MRI
yo
e acut cord and
un
my e syndr CSF
g
elit ome
adu
is
lts
Pure motor syndrome or
Viral myelitis Any age Acute-subacute segmental cord MRI and CSF
syndrome
Epidural Subacute; may Segmental cord
Any age MRI
abscess worsen abruptly syndrome
Usually >60 MRI with diffusion-
Infarction Abrupt onset Anterior cord syndrome
years weighted sequences
>40 years
(dural fistula)
Vascular Acute and/or MRI, spinal
20s Radiculomyelopathy
malformation stepwise angiography
(intramedullary
AVM)
Subacute
Slowly
combined Any age Dorsal cord syndrome Vitamin B12 levels
progressive
degeneration
Slowly
progressive; Segmental cord
MRI, clinical
Radiation Any age beginning 6 to 12 syndrome or ventral
history
months after cord syndrome
radiation therapy
Children, Slowly
Syringomyelia Central cord syndrome MRI
young adults progressive
Epidural Usually >50 Subacute; may Segmental cord
MRI
metastasis years worsen abruptly syndrome
MRI with
Intramedullary Slowly
Young adults Central cord syndrome gadolinium
tumor progressive
enhancement
Usually >60
ALS Progressive Pure motor syndrome Electromyography
years
MRI: magnetic resonance imaging; CSF: cerebrospinal fluid; AVM: arteriovenous
malformation; ALS: amyotrophic lateral sclerosis.
* This is a partial list of causes. Refer to UpToDate topics on disorders affecting the spinal
cord for a more complete differential diagnosis.
Graphic 50336 Version 3.0
Red flags in patients with neck pain
Symptom or Clinical
finding significance
Raises
concern for
Recent major neck
cervical
trauma
spine
fracture
Neurologic Raises
symptoms or signs concern for
that suggest spinal cervical cor
cord issue (eg, d
weakness, gait
difficulty, bowel or
compression
bladder
dysfunction)
Suggestive
Shock-like
of cervical
paresthesia
cord
(Lhermitte's
compression
phenomenon) with
or multiple
neck flexion
sclerosis
Suggestive
Fever or chills
of infection
Raises
concern for
History of injection
cervical
drug use
spine or disc
infection
Raises
Immunosuppressio
concern for
n
infection
Raises
concern for
infection or
Chronic
cervical
glucocorticoid use
spine
compression
fracture
Suggestive
Unexplained weight
of
loss
malignancy
Raises
concern for
metastatic
History of cancer
disease to
cervical
spine
Suggestive
of rheumatic
Headache, shoulder
disease (eg,
or hip girdle pain,
polymyalgia
or visual symptoms
rheumatica,
in older patient
giant cell
arteritis)
Suggestive
of a non-
Anterior neck pain spinal cause
(eg, angina
pectoris)
Graphic 114880 Version 3.0
Passive
Lateral
Upper
Spurling
Manual
Cervical
trapezius
bending
neck
neck
spine
maneuver
distraction
rotation
imaging
of
muscle
the
to detect
neck
of
palpation
test
adults
for
cervical
cervical
following
radiculopathy
radiculopathy
trauma Radiation dose
estimates for
spine imaging
Procedure Approximate effective dose Comparable duration of
(mSv) natural background
radiation (years)
Spine radiograph (x-ray) 1.5 0.5
CT spine 6 2
Fluoroscopic interventional 5 1.7
angiogram of the head and neck
CT angiogram of the head and 14 4.7
neck
CT: computed
tomography.
Data from:
1. RadiologyInfo
.org.
Available
at: https://w
ww.radiologyi
The upper portion of the trapezius muscle originates from the nfo.org/en/inf
seven cervical spinous processes and the distal aspect of the o.cfm?
The Spurling maneuver is used to detect cervical radiculopathy.
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acromial process. Palpate
and facet thejoints
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vertebral muscle
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the universal is sign
performed
of neck with the head
pathology. Theheld in a
degrees laterally.
tenderness can result
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trauma,
is asked buttothe
relax.
majority
The examiner
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patient
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is
to one asked
reactive The
to
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on examiner
relax.
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strain. presses
places
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on of
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CT: head.
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tomography; reproduce
OR: the
operatingpatient'sis pain,
room; the procedure
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Courtesy of Maria E Moreira, MD. computed
Graphic 93206 Version 2.0 tomography
examinations and the associated lifetime attributable risk of cancer. Arch Intern
Med 2009; 169:2078.
Graphic 55620 Version 7.0
Contributor Disclosures
Zacharia Isaac, MDNothing to discloseHillary R Kelly, MDNothing to
discloseSteven J Atlas, MD, MPHGrant/Research/Clinical Trial Support:
Boehringer Ingelheim [Atrial fibrillation]; Bristol Myer Squibb/Pfizer Alliance
[Atrial fibrillation]. Employment: Healthwise Inc [Patient education
material].Jeffrey G Jarvik, MD, MPHEquity Ownership/Stock Options:
Physiosonics [HIFU (ICP monitors)].Lisa Kunins, MDNothing to
discloseSusanna I Lee, MD, PhDNothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial
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