Metastatic epidural spinal cord compression / Thoracic spine

Figure 2. Epidural spinal cord compression on magnetic resonance imaging (MRI). Sagittal T1-weighted MRI through the thoracic spine demonstrates lymphoma (arrows) involving the T5 and T12 vertebral bodies extending posteriorly into the spinal canal and compressing the spinal cord (c) at both levels. T8 indicates the T8 vertebral body, and A indicates anterior.
Adapted with permission from Quint DJ. Indications for emergent MRI of the central nervous system. JAMA 2000;283:854.


Metastatic epidural spinal cord compression (MESCC) occurs when cancer metatasises to the vertebral bodies of the spine or epidural space and causes secondary compression of the spinal cord. MESCC is a common complication of malignancy that affects almost 5 percent of patients with cancer. Systemic cancers with a tendency for spinal cord metastasis include the following: breast, prostate, renal, or lung neoplasms: lymphoma, sarcoma, and multiple myeloma. Most frequently metastatic seeding appears in the thoracic spine, accounting for about 70 percent of the cases.

MESCC is a medical emergency that needs rapid diagnosis and treatment if permanent paralysis is to be prevented. Appoxiamately 90 percent of patients who are ambulatory at the time of diagnosis do not lose this ability posttreatment. New back pain in patients with cancer suggests epidural spinal cord compression. Pain that worsens when the patient is lying down or with percussion of vertebral bodies is characteristic of the condition. Later neurologic signs like incontinence and loss of sensory function are associated with permanent paraplegia.

The diagnosis of MESCC is best determined with the use of magnetic resonance imaging. MRI has surpassed myelography as the imaging study of choice. Most patients with epidural spinal cord compression need radiation treatment or surgery. Asymptomatic patients should be considered for immediate radiation therapy, and patients with progressive symptoms despite radiation therapy should be considered for sergical intervention.

Hangman's Fracture / Cervical Spine

Figure 25. Sagittal T1-weighted MR image of the cervical spine shows a hangman fracture with ligamentous injury and extensive prevertebral and epidural hematoma







Figure 13. Sagittal T2-weighted MR image of the cervical spine in a pediatric patient shows a C2 fracture with disruption of the tectorial membrane (arrow), findings that indicate a severe and unstable injury.




A Hangman's fracture is a fracture of both pedicles or pars interarticularis of the axis vertebra, the second cervical vertebra(C2). The fracture can be with or without subluxation of C2 or C3 and often causes death.

The name Hangman's fracture came from a broken neck involving a fracture of an upper cervical vertebra similar to the injury suffered in death by hanging. The head would be forced into hyperextension by the full weight of the body and therefore the force and distraction of the neck would cause the fracture. Now days this injury is seen due to sports injuries, motor vehicle accidents, diving into shallow water, along with deliberate or suicidal hanging.

Severe pain will usually be present at the point of injury. Pressure on a nerve may also cause pain from the neck down into the shoulders and arms. Bruising and swelling may be present at the back of the neck. When these symptoms arise, Doctors will usually order X-rays to detemine the severity and location of any fracture. Also they may order a neurological exam to be performed to assess for spinal cord injury. CT scans may also be ordered to look for abnormallties not visible by regular X-rays. Also MRI tests can be ordered to provide high resolution images of soft tissue to further determine damage to the spinal cord. Worse senario a patient may experience immediate consequences of numbness and paralysis in much of the body which makes this a very serious and unstable injury.

When numbness and paralysis are the symptoms, complete immoblizaton of the head and neck should be done as early as possible and before moving the patient. Immobilization is imperative to minimise or prevent further spinal cord injury. Collars, and traction should be used to immoblize and stablilize the neck before diagnosis and when cervical fracture has been diagnosed.

Surgery may be needed to stabilize the neck to relieve pressure on the spinal cord. Different surgeries are available depending on the injury. Vertabrae may have to be fused together to provide stability. Metal plates, screws, or wires may be needed to hold vertabrae or pieces of the vertabrae in place.

Neck Vessels / Dissection of the Carotid Artery

Top: Magnetic resonance angiography of right carotid artery dissection 2 cm from bifurcation (on left side). Bottom: Magnetic resonance angiography of right carotid artery dissection with clot in the wall (on left side). Dissection stops below skull base. Images contributed by Philip Kousoubris, MD.



Arterial dissection of the carotid arteries occurs when a small tear forms in the innermost lining of the arterial wall. Blood can enter into the space between the inner and outer layers of the vessel, causing stenosis or complete occlusion. Blood clots, or emboli originating from the dissection are thought to be the cause of infarction in the majority of cases of stroke in the presence of carotid artery dissection.

Carotid arterial dissections can be categorized as traumatic or spontaneous. Traumatic dissection is the result of either external mechanical injury, like blunt trauma, or trivial trauma that is related to a movement or abrupt change in head position, and sometimes strenuous physical exertion. Spontaneous dissections have no definitive precipitating factor, however they may be associated with systemic hypertension, connective tissue disorders, smoking, diabetes, oral contraceptives, a family history of cerebral infarction or cerebral and abdominal aortic aneurysms.

The signs and symptoms of carotid artery dissection may be divided into two categories:
Ischaemic
Decreased pupil size with drooping of the upper eyelid
Transient vision loss
Ischemic stroke

Non-ischaemic
Headaches
Neck pain

Recognizing a dissection early is essential because prompt anticoagulant therapy and endovascular repair greatly minimize the patients risk of infarction/stroke, neurologic disability, and death. Cervical arterial dissections are relatively rare. The combined incidence of both vertebral and carotid dissections is estimated to be 2.6 cases per 100,000 population. However, cervical arterial disections are the underlying reason in as many as 20 percent of the ischemic strokes that occur in patients 30 to 40 years old.

Nearly all imaging modalities have been used to demonstrate cervical arterial dissections. In the past conventional catheter angiography has been the standard for the diagnosis of arterial dissection, however increasing reliance has been placed on reconstructed cross-sectional imaging techniques, including CT scanning and MR angiography because of the noninvasive nature of these modalities. The many advantages of MRA's has made this the preferred method for the initial screening and evaluation of patients with suspected arterial dissection.

Soft Tissue Neck / Ranula

Figure (a) Axial T2 weighted MRI shows a high signal lesion in the left sublingual space extending to the submandibular space consistent with a plunging ranula (arrow). (b) Axial T1 weighted MRI with gadolinium enhancement of the same ranula showing minor rim enhancement of the cystic lesion (arrow)


MRI Coronal STIR and MRI T2 Sag images





A Ranula is a type of mucocele found on the floor of the mouth and usually involves the major salivary glands. Ranulas occur as a result of trauma or obstruction to the salivary gland excretory duct and spillage of mucus into the surrounding soft tissues. These lesions are divided into two types: oral ranulas and cervical or plunging ranulas. Oral ranulas are secondary to mucus extravasation that pools around the mylohyoid muscle, and the cervical or plunging ranulas are associated with mucus extravasation along the fascial planes of the neck.

A Ranulla looks like a bluish cyst located below the tongue. The cyst may fill the mouth and raise the tongue. Typically theses cysts are painless masses that do not change in size in response to chewing, eating, or swallowing. Ranulas tend to be relatively painless with little or no associated morbidity or mortality. Depending on the size and location, some ranulas may interfere with normal mastication.

Plunging ranulas can manifest as neck swelling in conjunction with, or independent of a ranula cyst on the floor of the mouth. Most reported plunging ranulas are 4 to 10 centemeters in size and are usually found in the submandibualr space. They have been reported to extend into the submental region, the contralateral neck, the nasopharynx up to the skull base, the retropharynx, and even into the upper mediastinum. Oral and plunging ranulas may affect swallowing, speech, or mastication and may result in airway obstruction. The very thoracic ranula may compromise respiratory funtion and may be life threatening.

Ranulas usually occur in children and younger adults. The cervical or plungling varient tends to occur a little later in life.

CT scanning is used to diagnose Ranulas, however MRI scanning is the most sensitive imaging study to evaluate the sublingual gland and its pathologic states. Many Ranulas resolve on their own and do not require surgical intervention. Medical therapy with medication is also a form of treatment. However if there is an airway obstruction or some sort of feeding problems, surgery is indicated.