Welcome to Rayence Educational Series in partnership with Drs. Terry R. Yochum and Alicia M. Yochum.

Images from radiology practice submitted by Chiropractors throughout the United States will be displayed here with a review and basic description provided by Drs. Terry and Alicia Yochum! This is intended to be a brief discussion with a select group of images so the doctor can review them in a short period of time and learn what the experts see in those images.

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Case History

This 60 year old male patient presents with low back pain and sciatica. He relates a history of playing high school football where he went to punt the ball and missed the ball with a defensive player running under his leg causing him to further extend his leg. He developed immediate pain in his buttocks.

Diagnosis – Rider’s Bone (Ischial Tuberosity Avulsion)

Note the extensive bone production seen inferior to the lateral aspect of the left ischial tuberosity. This represents an avulsion of the secondary growth center (apophysis) for the ischial tuberosity as a result of the forceful contraction of the hamstring while trying to kick the football.

These can be acute or chronic injuries or frequently bilateral. With healing, overgrowth of the avulsed apophysis occurs, often leaving a wide radiolucent gap between the avulsed fragment and the parent ischium. This overgrowth may be the effect of increased blood flow to the ischial apophysis.

Occasionally the involved ischial apophysis may assume a size larger than the parent ischium. This large overgrowth could be confused with an osteochondroma if attached to the bone. The patient’s history of a previous severe hamstring injury and the fact that the lesion is asymptomatic secures the proper diagnosis. Reduction in hip mobility is common and surgical intervention has not been encouraged. These fractures are seen most commonly in cheerleaders and hurdlers. Since chronic stress often produces this lesion in horseback riders the residual bony fragment has been called “Rider’s Bone”.

History: 52-year-old male patient with deep seated neck pain and reduced range of motion.

There is an extensive amount of spinal hyperostosis noted from C2 through C6 on the anterior aspect of the vertebral bodies. This spinal hyperostosis is very characteristic of diffuse idiopathic skeletal hyperostosis (DISH). These patients have a reduced range of motion and can experience dysphagia. An additional finding in this patient is degenerative disc space narrowing at the C2/3 level. All the remainder of the cervical discs and the facets are reasonably well preserved. That is often a characteristic finding of patient’s with DISH.

This patient additionally has congenital agenesis of the posterior arch of the atlas with a posterior arch and tubercle of the atlas fusing to the spinous process of C2 creating a characteristic “mega spinous process sign”. Note the anterior tubercle of the atlas is enlarged by means of hypertrophy. This occurs as a result of altered upper cervical biomechanical movement.

An additional finding associated in some patients with DISH is ossification of the stylohyoid ligament which is noted here. This is seen just above the hyoid bone and extending to the styloid as a very large ossific bar. Patients with DISH on occasion may fuse the posterior longitudinal ligament (OPLL). Ossification of the posterior longitudinal ligament may produce spinal stenosis and symptoms in the upper and lower extremity. These findings should be looked for very closely clinically. This appearance of spinal fusion is quite different than the finer and delicate areas of bone spurring and fusion associated with ankylosing spondylitis.

The two cases presented here demonstrate the benign presentation of spina bifida occulta. There is a benign spina bifida occulta affecting the C7, T1 and T2 segments without evidence of block vertebrae or congenital fusion. In the cervical spine most cases of spina bifida occulta are not symptom generating and are not associated with any other abnormalities. However, if spina bifida occulta should occur at C5 or C6 as an isolated entity it may be associated with true cervical spondylolisthesis with lack of development of the pars–lamina area. The additional case here demonstrates spina bifida occulta at L5 which carries a higher incidence of an association with pars defects and/or spondylolisthesis. Many patients with benign spina bifida occulta at L5 do not have spondylolisthesis but many do. So, when viewing spina bifida occulta at L5, one should always look very closely for defects in the pars and if necessary, obtain oblique radiographs to rule out a pars interarticularis defect.


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