Radiology Corner – Fracture or No Fracture?

By Terry R. Yochum, DC, DACBR, Fellow, ACCR and Michael S. Barry, DC, DACBR

History

This 35-year-old female patient presents with a history of severe “whiplash” and cervicodorsal pain. An abnormality of T2 is identified. Is this a fracture? Is additional imaging necessary to confirm this?

Figure 1.

Figure 1.

Figure 1 Diagnosis: The abnormality at the T2 vertebral segments represents a spina bifida occulta and not a fracture. Notice the radiolucent line is “clear and smooth” and has sclerotic margins, which would be atypical for a fracture. Additionally, a clay shoveler’s type fracture (avulsion of the spinous process) is very rare at the T2 level; however, it has been documented. No additional imaging is necessary. The final definitive diagnosis of congenital anomaly rather than fracture can be made from the plain films alone.

Discussion

Spina Bifida Occulta. The laminae meet and close posteriorly to form the spinous process. A small defect in this area will result in a cleft spinous. When this defect is mild, with only a small void in the osseous development, it is known as “spina bifida occulta.” This is not known to cause back pain and is considered to be of no clinical significance. It may on occasion be confused with fracture and the clear demarcation line and sclerotic margins help in this differential diagnosis.

Spina bifida occulta occurs more commonly in males at the L5 and S1 levels in a 9:1 ratio. This defect is seen well on the anteroposterior radiographs of the spine.

A more severe variant of spina bifida is spina bifida vera. This defect may be considerably larger than that found in spina bifida occulta and is associated with a protrusion of the meninges and/or spinal cord. It is the spina bifida vera form that may produce severe neurological deficit.

Reference

1. Yochum TR, Rowe LJ. Essentials of Skeletal Radiology, 2nd ed. Baltimore, MD: Williams & Wilkins, 1996.

About the Authors

Dr. Terry R. Yochum is a second generation Chiropractor and a cum laude graduate of the National College of Chiropractic, where he subsequently completed his radiology specialty. He is a Diplomate of the American Chiropractic Board of Radiology and served as its vice-president and president for seven years (1983–1990).

Dr. Michael S. Barry is a 1988 cum laude graduate of Palmer College of Chiropractic. He completed a three-year radiology residency at Logan College of Chiropractic following two years of clinical practice in Las Vegas, Nevada. He received his diplomate in radiology from the American Chiropractic Board of Radiology in 1992.