1. Case of the Week 93 This 62 year old male presented to the practice of Carole Beetschen, DC, Genève, Switzerland with an insidious onset of increasing neck pain. After the history (stomach cancer in 2005 with ablation and chemotherapy. Liver mets in 2008) and examination (no neurological deficits. Stiff neck, especially in lat flexion) she referred him for the following test.

2. Coronal Bone Window CT slice through the bodies of the cervical spine. What is abnormal? What is the likely diagnosis or DDX? (See next slide)

3. Additional soft tissue window CT slices for this patient

4. Answers Abnormal CT findings Abnormal CT findings Lytic destruction of the posterior and right side of the body of C3 is noted with cortical destruction and partial collapse. Lytic destruction of the posterior and right side of the body of C3 is noted with cortical destruction and partial collapse. The right vertebral artery is displaced laterally by a soft tissue mass. The right vertebral artery is displaced laterally by a soft tissue mass. Differential Diagnosis Differential Diagnosis The most likely diagnosis at this age must always be lytic metastatic disease. Multiple Myeloma is a good differential diagnosis. The most likely diagnosis at this age must always be lytic metastatic disease. Multiple Myeloma is a good differential diagnosis.

5. Same patient 2 ½ months later Notice the further pathological collapse of C3, extending into the spinal canal. This was a proven case of Lytic Metastasis.

6. The same 62 year old male also has a history of LBP. (The patient has the right to more than one condition.) What is the diagnosis? Mid sagittal CT sliceParasagittal slice

7. Answer Diagnosis: Diagnosis: Spondylolytic spondylolisthesis L5 with marked degenerative disc disease. The pars defect on one side is nicely seen on the parasagittal slice. Spondylolytic spondylolisthesis L5 with marked degenerative disc disease. The pars defect on one side is nicely seen on the parasagittal slice. Limbus bone anterior superior L4. Limbus bone anterior superior L4.

8. What would the imaging findings of the C3 vertebra looked like on MRI? Low signal intensity on T1 weighted images Low signal intensity on T1 weighted images High signal intensity on T2 and STIR (fat suppressed) weighted images. High signal intensity on T2 and STIR (fat suppressed) weighted images.