Document Sample
					VOL.       lOS,    No.

                   CERVICAL      VERTEBRAL                                                                                           EROSION     CAUSED                                                                          BY
                         VERTEBRAL       ARTERY                                                                                         TORTUOSITY*
                             By    HAROLD                     B. ZIMMERMAN,                                           M.D.,          and           WALTER                    J. FARRELL,                            M.D.
                                                                                                FALLS             CHURCH,             VIRGINIA

          NGIOGRAPHY                                     is         utilized                    with               in-                    Cervical               myelography                            showed             no         abnormal-
               creasing               frequency                        to            help               deter-                     ity.
mine              the          nature         and                   extent                  of          space-                            Left       vertebral                 angiography                        (Fig.          i,     C and              D)
                                                                                                                                   was        performed                      via          retrograde                 injection                    of      the
occupying                     lesions.       The     usual     positive                                         find-
                                                                                                                                   left       brachial                 artery.              The          left       vertebral                     artery
ings include                    vasculardisplacement,invasion,
                                                                                                                                   appeared                   of somewhat                        large   through-
and            abnormal                  tumor           vessels.                    Occasionally
                                                                                                                                   out       its         entire      length.    Opposite         C , that     vessel
an        aneurysm                    is found              to      be         the         questioned
                                                                                                                                   exhibited                  localized      medial      looping    from its nor-
mass.              In       the       2  cases     presently                                described,                             maily             straight                course               through                 the         transverse
unusual                  loops        of tortuous,        but                        not      aneurys-                             foramina.         Less                      pronounced        posterior                                  and           an-
mal,            vertebral               arteries              were             shown                  by         vas-              tenor     deflections                          were apparent.         The                                tortuous
cular             studies             actually                 to        be          the         cause                  of         segment                    coincided                   precisely                 with              the          body-
tumor_simulating                                     erosions                        of            cervical                        pedicle      defect.      There      was also slight         tortuosity
vertebral                    bodies           and       pedicles.                                                                  of the artery         opposite       C . However,            no erosion
                                                                                                                                   of that vertebra            could     be identified.
                                  REPORT               OF        CASES                                                                 Because        it was       felt   that   the    patient         might
                                                                                                                                   benefit     from decompression,              surgery       was under-
    CASE I. A 50 year old woman                      sought       medical
                                                                                                                                   taken.     The       entire     left lamina        of C          and the
attention          because         of increasingly          severe        left
                                                                                                                                   superior                  aspect          of      the        left      lamina                of      C              were
occipitocervical             pain of about          2 months’          dura-
                                                                                                                                   removed.                A very          slightly         pulsating         reddish
tion. She described               this as throbbing           and rather
                                                                                                                                   mass            was      noted       immediately             above       the C
constantly          present,        tending      to originate         in the
                                                                                                                                   nerve            root,      apparently           extending          toward        the
lower      posterior       part of her neck and to radiate
                                                                                                                                   anterior            neck.      This grossly           resembled         a tumor.
toward        her left ear. The patient                   reported         oc-
                                                                                                                                   Insertion              of a needle,           however,           demonstrated
casional       nausea        and a few brief episodes               of ver-
                                                                                                                                   spurting             arterial      blood.
tigo during          this period.         Aspirin,     pentobarbital,
                                                                                                                                       The           patient       recovered          uneventfully.           She re-
and tranquilizers               provided        no relief.     Her phy-
                                                                                                                                   ports           occasional         vague       discomfort          in her lower
sician      sent     her to an orthopedic                surgeon         who
                                                                                                                                   neck            and          upper              back.           However,                     the         initially
roentgenographed                              her      cervical                spine            and          noted
                                                                                                                                   described                    cervical             pain          and          occipital               headache
the        vertebral              finding            described                  below.                The          pa-
                                                                                                                                   have            not        recurred               io        months             after          surgery.
tient           was      in turn          referred             to a neurosurgeon.
         The patient’s     past                     history was unremarkable.                                                             CASE            II. A 70 year          old widow      reported     in-
         General     physical                        and neurologic    examina-                                                    creasingly                frequent        episodes      of light-headed-
tions           were         entirely          normal.                                                                             ness. These                had begun         about    3 years earlier    and
         The          anteroposterior                    roentgenogram                                     of      the             lately           occurred        at least     3 times   each week, most
cervical      spine   revealed                           a radiolucent       area, per-                                            commonly                       in     the        morning.                    Some            of      the            more
haps     with      a slightly                          sclerotic      medial     margin,                                           recent             attacks              were            said         to last            up         to      i        hour.
along    the left lateral                            aspect      of the body of C .                                                The           patient               denied              headache,                   neck            pain,             and
This     was      demonstrated                               somewhat        better      by                                        paresthesias.                       She         had          been        found               to     be         hyper-
laminagraphy                          (Fig.         i1).     The left anterior          ob-                                        tensive   4 years    earlier     and regularly     took chlor-
lique projection                         (Fig.         iB)          localized                   the          lesion                thiazide.
to        the         posterosuperior                     portion                    of     the             lateral                    Blood   pressure       currently      was 200/100        mm.
body              surface.              The         inferior               half            of         the          left            Hg. Moderate         retinal      changes    of hypertension
pedicle      of C       was also                        eroded,   the                      body             defect                 were    observed.                         Physical                  and neurologic                             exami-
being      continuous         with                      the enlarged                          C                       in-          nations      revealed                       no other                  abnormality.
tervertebral         foramen.                                                                                                             Roentgenograms                                  of      the       skull          showed                      para-

     *   From      the Department              of Radiology,             the    Fairfax          Hospital,              Falls   Church,          Virginia.

768                                                        Harold              B.      Zimmerman                     and          Walter                  J. Farrell                                                                   APRIL,         1970

Fic.           I.     Case        I.   (A)    AnteropoSterior                  larninagram                 reveals         a lucent              area         along            the        left        lateral             aspect              of C .
        ( B)        Oblique            roentgenogram                clearly           demonstrates               erosion           of      the        posterosuperior                            portion              of         the         body          of
     C              and      the adjacent              inferior
                                                      of its left pedicle,
                                                                    aspect        with resulting        enlargement        of the C            interverte-
     bral foranlen.      (C) Anteroposterior       and (D) lateral       arteriogranls          made      following   retrograde       injection           of tile
     left brachial    artery  Show the left vertebral          artery   to be of larger          diameter        than usually     seen. Opposite              C
     it abruptly    extends    medially      and, to less degree,     posteriorly        and then anteriorly.            Its course     corresponds             to
     the bone defect. The artery also exhibits               some tortuosity           opposite      C 5, but no erosion           of that vertebra              is
     discernible    on the plain roentgenograms.

sellar    carotid        artery                         calcification.                 An       antero-              thought                     to       be           a Ileurofibroma                              (neurolem-
posterior       roentgenogram                                  of the           cervical             spine           moma,                    schwannoma).                                       A          meningioma                                  in-
(Fig.     2A)      revealed                          a very            sharply               outlined                frequently                         may             prodluce                     this         findling.                   Other
sclerotic-rimmed                             radiolucent               the left
                                                                      area     along
                                                                                                                     less         likely              possibilities                        include                  the          more               rare
aspect    ofC 4, with a less clearly                  defined         lucency
                                                                                                                     spinal             neoplasms                        as lipoma,                         epidlermoidl,                           and!
along     the same           part     of C .          A left anterior
                                                                                                                     tera         toma            ; hernia               ted!         meningocele                                ; and!             ver-
oblique      view      (Fig.      2B)    demonstrated                erosions
of the posterosupenior                portions        of the left sides                                              tebral                  artery                    aneurysm.                            Congenital                               ab-
of those      bodies      and tile inferior           aspects         of their                                       sence              or        hvpoplasia                          of         a ped!icle                       will           like-
left pedicies,          the defects          seeming          continuous                                             wise           suggest                     tile          appearance                             of          foraminal

with adj acen t in tervertebral                  foramina.                                                           enlargement.                               Tile  presently                                 reported!                      cases
     Left   vertebral         arteniography            (Fig.      2,     C and                                       call attention                              to an apparentl\-                                   little                  recog-
D) was       obtained!        by retrograde             brachial          i,jec-                                     nized!             cause              Whicil,                   in      fact,                may                  be       more
tion.               This         confirmed             tortuous           segments                of      the        common                      than            most,               or      perhaps                      all,          of      those
vertebral                     artery          to course        medially      and  an-                                conditions                         mentioned!                         above.
teriorly                   opposite           C        and C , corresponding
                                                                                                                            That             a tortuous                         loop             of vertebral                                artery
to the                radiolucent               defects    evident      on the plain
                                                                                                                     may           produce                      bony            change                      was           reported!                     by
roen           tgenognams.
                                                                                                                     Hadley2                     on       the           basis             of IliS meticulous                                        dis-
    A clinical       diagnosis    of cerebrovascular            in-
sufficiency     was made.      An ticoagulation         therapy
                                                                                                                     sections                    of cadavers                              necks              and            correlation
was begun,        and tile patient     has been      relatively                                                      of the              findings                      with        postmortem                            roentgen-
asymptom       atic.                                                                                                 ograms.                Four                of       21      dissected                        specimens        ex-
                                                                                                                     hibited     vertebral                                defects,   ranging                                     from    sub-
                                                                                                                     tle erosion        along                             the posterolateral                                         margin
        The               most         common               cause         of         widening              of        of a body                        to complete                          absence                    of a pedicle.
an             intervertebral                           foramen                 is       generally                   In       2   of those                       cervical                  spines,                 multiple                      sites
\OL.          ioS,        No.                                      Bone         Erosion                     by     Vertebral                  Artery               Tortuositv                                                                               769

FIG.          2.     Case          II . (il)       Anteroposterior        roen   tgenogrdlll           denlonstrates               a sharpl’                                           denlarcated,                      sclerotic-ri                  mIlled
       radiolLicency     overlying        the                     aspect
                                                                 left          of C . A somewhat                         less well-defined                                               lucent         area             is also             present              in
       the correSponding          portion                    of C ,. (B) Left              anterior        oblique          roentgenogranl                                                reveals           thinning                    fronl             below
       of the left pedicles                        of C 3 and C , with erosion                 extending           along       the posterosuperior                                                    aspects               of those                 bodies.
       ( C and D) Anteroposterion                            and  lateral      arteriograms              made         following         retrograde                                            l)rachial                injections                    denlon-
       strate,            as in Case              I,   that          the left vertebral                     artery is somewhat       larger than usual.        Loops                                                of the artery                          pass
       medially                 and      anteriorly                 opposite              C          and!   C 3, overlying   the   previously    noted     erosions.                                                     Slight              tortuositv
       is also present                       opposite              C 6, where,                     however,      no bone abnormality        can be identified.

of erosion                        were          evident.                  Incidentally,                          Had!-             to         Ilave           had         cenebrospinal                                  syphilis,                        were
ley          feels         that          2    cases        wilich              he         ilad!      published!                    significantly           old!en                          tilan             tile             patient                       die-
earlier    as instances                                  of congenital                              absence               of       scnibed       b\- Sloven                             and    Kiley                       and                tile          one
a cervical       ped!icle                               instead!     may                            Ilave         been             pnesentl-        reported!                            in Case                  i.       Whether                          the
examples                        oferosion                  by         a tortuous                      vertebral                    basic               arterial  abnormality                                        is       the             same                 in
artery.                                                                                                                            tile           2   age groups     is uncertain.
       Whereas                         Hadley’s                     study                 utilized                post-                     Several             other          possi      ble         causes                of vertebral-
mortem                      material,                   Sloven                 and            Kilev4              dem-             artery                tortuoSitv                     might             be               briefly      men-
onstrated                         angiographicallv                                   in       a living               pa-           tioned.
tient              that          an abnormal                          loop           of vertebral                     ar-                   (a)        Epstein’                notes          that         diilatation                           of one
tery               corresponded                           to        a defect             along                   a cer-                                or both           vertebral                    arteries        may                        be sec-
vical              body     and                pedicle.              Their            case and                    those                                ondarv              to      an         arteniovenous                                     malfor-
reported                        in this          paper,               particularly                          Case              i,                       mation             in the             posterior                      fossa.                   He      in-
present                    near-identical                             roen       tgenologic                       find-                                cludes    roentgenograms                                             from                such   a
Ings.                                                                                                                                                  case   which      5110w                         erosion                     of         the lat-
        In         each           of         Hadley’s                 proven                   cases,            path-                                 era! aspects     of C i and   C 2 by                                                           a tor-
ologic               examination                          of the             tortuous                   segment                                        tiious   segment    of an enlarged!                                                             feed-
of       artery                  revealed                 d!egenerative                              change               (                            ing”   vertebral    artery.
arteriosclerotic                                and!           I  possibly    luetic    in or-                                              (b)        In     several             of Had!lev’s                           specimens,                             an
igin).      He                   feels         that            the tortuositv        is prob-                                                          arthrotic                 posterior                   a nticula                       tion           ap-
ably   acquired!      but allows         that                                           in some     cases                                              peared             to      diisplace                 the            vertebral                         ar-
it may      be congenital.         All of                                             these   patients                                                 tery           forward               at        the       level                   of       its        ab
of Hadley,       with     tile exception                                                      of      I thought                                        normal             course.
                                                           Harold                   B. Zimmerman                             and       Walter                  J. Farrell                                                          APRIL,         1970

Neither                 of        these             possibilities                        seems                appli-                                                           SUMMARY

cable         to        the        currently                 reported                     cases.                                    Several                 cases             now           have             been          reported                  in
       Review                 of the            cases           described                       to date                in-   which               erosion                 of      a cervical                      vertebral                  body
dicates        the fourth         cervical     vertebra          to be                                                       and          pedicle                  has         been              shown               angiographic-
the     one      most    commonly           erod!ed.       Involve-                                                          ally         to        be       caused                  by         tortuosity                  of       a verte-
ment        has     been      predominantly             left-sided.                                                          bral         artery.              A cited                 postmortem                           study      sug-
This     may      be related!      to the fact that           the left                                                       gests          that            this         may          occur     rather                     frequently.
vertebral                 artery                is larger               than             the      right            in a      The          predominant                           anterosuperior                              direction
higher             percentage                       of ind!ivid!uals                           than   is the                 ofthe          resulting                     intervertebral                             foraminal        en-
reverse              situation.3                      Five     of the                          7 patients                    largement                       appears                      characteristic,                           and          this
thus         far        reported                    have         been            women.                                      may               be          helpful               in         making                   the         diagnosis
       The          tortuous                     loop            of vertebral         artery                                 from           plain             roentgenognams.
usually              has           extended                     medially,     anteriorly,                                           Etiology                   of the                 tortuosity                     and            relation-
and          slightly                    superiorly.                      Accordingly,                                 fo-   ship          of        the        finding                   to         the     patient’s                    symp-
raminal                 enlargement                         has           occurred                      pnimar-              toms           remain                  uncertain.
ilv       in an          anterosuperior                            d!irection                     (Fig.   iB;                Harold             B. Zimmerman,                             M.D.
and!        2B).          The             erosion               thus     has               not       been   as               3300         Gallows             Road
symmetric                         or         concentric                   as        in         other            fora-        Falls        Church,              Virginia               22046

men-enlarging                                conditions.                                                                            The              authors                   thank                   Ronald                 A.          Apter,
       Had!le                 does            not       present                information                             re-   M.D.,                  and!       Ronald                     J. Bortnick,                        M.D.,                for
gard!ing                clinical               symptoms.                       The             patient                 re-   their          permission                          to        report             the          above             cases,
ported!             by         Sloven               and!        Kile\-,             a 3                year         old      and           Andrew                    I. Dobranski,                                   M.D.,                for      al-
woman,                   complained!                       of       3   months                     of inter-                 lowing                 reproduction                               of     the        roentgenogram
mittent                 throbbing                      neck         pain,    with                   left pre-                shown                  in Figure                   iB.
auricular,                    postauricular,                            and!         occipital                   par-
esthesias.                   No         surgery            was           performed!.                       A per-            I.     EI5TEIN,                 B. S. The                    Spine:            A Radiological                      Text
sonal              communication                                  from              one            of          those                      and            Atlas.   Third                        edition.            Lea        &        Febiger,
authors                   (W.P.S.)                     indicates                     that               the        pa-                    Philadelphia,                       1969,                   707-708.

tient’s             symptoms                            subsid!ed                    shortly                    after        2.     HADLE\-,                L. A. Tortuosity                           and       deflection            of verte-
                                                                                                                                          bral             artery.    AM.                       J.         ROENTGENOL.,                         RAD.
d!ischarge                     from              the       hospital                      and!           are         be-
                                                                                                                                          THERAPY                  & NUCLEAR                        MED.,         1958,       80,     306-312.
lieved            not         to have                recurred.                 The             patient              (le-     3.      KRAVENIICHL,         H., and IASARGIL,        M. G. Die
scribed              in        Case             i has           had!           no        apparent                      re-                vaskul#{228}ren Erkrankungen        im Gebiete    der
currence                  of           her      preoperative                             cervical                  and!                   Artenia Vertebralis      und Artenia Basialis. Georg
                                                                                                                                          Thieme             Verlag, Stuttgart,                              1957.
occipital                 d!iscomfort,                     although                       the          relation-
                                                                                                                             4.     SLOvER,                W. P., and KILEV,                          R. F. Cervical                         verte-
ship         of      the           symptoms                       to       the           vascular                  ab-                    bral erosion               caused               by tortuous      vertebral                        artery.
normality                     is admitted!ly                            uncertain.                                                        Radiology,                 1965,84,                   112-114.