Table Of ContentExercises in Radiological Diagnosis
Auguste Wackenheim
Cervico-Occipital Joint
(RX, CT)
158 Radiological Exercises for Students
and Practitioners
With 334 Illustrations
Springer-Verlag Berlin Heidelberg New York Tokyo
Professor Dr. AUGUSTE WACKENHEIM
Hospices Civils de Strasbourg
Centre Hospitalier Regional
Service de Radiologie I
1, Place de I'Hopital
F-67091 Strasbourg Cedex
Translated from the French by
MARIE-THERESE WACKENHEIM
ISBN-13: 978-3-540-15327-6 e-ISBN-13: 978-3-642-70381-2
DOl: 10.1007/978-3-642-70381-2
Library of Congress Cataloging in Publication Data. Wackenheim, A. (Auguste), 1925-
Exercises in radiological diagnosis of the cervico-occipital joint. Translation of: Exercices
de radiodiagnostic de la charniere cervico-occipitale. Bibliography: p. Includes index.
1. Atlanto-occipital joint-Radiography-Problems, exercises, etc. 2. Atlanto-occipital
joint-Radiography-Case studies. I. Title. RD763.W3313 1985 617'.375 85-14691
ISBN-13:978-3-540-15327-6 (U. S.)
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2127/3130-543210
"The true mystery of the world is the
visible, not the invisible."
OSCAR WILDE
(The Picture of Dorian Gray)
Preface
Like my first book of exercises in radiological diagnosis con
cerning the vertebrae in adults, the first part of this book
consists of an atlas of images ready for immanent reading.
The images are numbered, each number corresponding to a
case.
The second part comprises the corresponding comments,
critical interpretations, and drawings (using the same num
bers as the corresponding radiographs in the first part).
I hope that this second booklet will be as appreciated as
was the first, which was published in four languages (Radio
diagnosis of the Vertebrae in Adults. Springer, Berlin Hei
delberg New York 1983).
My own documentation having proved deficient in some
fields, I had recourse to the didactic collections oimy collea
gues, friends, and students. Special thanks are due to Prof. J.
F. Bonneville, and to Drs. J. L. Dietemann, Y. Dirheimer,
J. C. Dosch, and J. Vignaud.
AUGUSTE WACKENHEIM
VII
Contents
Introduction ..... 1
Part One: Iconography 5
Part Two: Commentary with Corresponding Schemata. 107
References . . 189
Subject Index 191
IX
Introduction
The analysis or the reading of an X-ray picture proceeds from struc
turalistic rules, such as the immanence, the synchronism, the significa
tion (signifiant and signifie of a sign), first from the semeiologic and then
from the semantic point of view.
In a simpler way, one can say that it is necessary to distinguish the
signifiant, the signi£ie, the comment, the interpretation, and the
radiobioclinical confrontation.
The signifiant or character is a normal or pathological "characteris
tic" part of the image.
Examples: are the sella turcica, crista galli, spinous process of the tibia,
fracture line, osteoma, and aneurysm.
The signifie is normal, specific for a group of diseases, or pathognomonic
of a particular disease.
Examples:
Normal: In this case the signifiant and signifie are identical. This
represents the normal radio anatomy.
Specific: An osteophyte can be present in different diseases of a
group, e. g., arthrosis, arthritis, discopathy, and infections.
Pathognomonic: Syndesmophytes occur only in a single disease,
i. e., spondylarthritis.
The comment is the text describing the signifiant of the sign. This
description proceeds by analogy with regard to normal and pathological
anatomy.
The interpretation is the text that criticizes and develops the com
ment; it describes the signifie of the sign. It has recourse to taxonomy,
nosography, etiology, indications for additional investigations,
pathogeny, treatment, and the connections between the image and the
patient's objective and subjective complaints. The image cannot be
interpreted.
An image can be commented upon and the comment is then
interpreted.
1
Example: Case 7 shows a malposition of the atlas combined with
malformation of the odontoid. The comment describes the morphology
and the topography. The interpretation indicates an origin, a mecha
nism, etc.
Comment: Disalignment, hypoplastic odontoid, etc.
Interpretation: C1-C2 dislocation with luxation of the atlas in a case
of congenital dens aplasia.
The radiobioclinical confrontation is an action unlimited in time
which may lead to modification, rectification of adaptation of the
interpretation; it cannot intervene upon the comment. As a matter of
fact, the comment is definite and immutable. The interpretation may
adapt itself to the context, to the clinical data, to the cultural level of
medicine, and to its therapeutic possibilities. The comment is uncon
nected with these factors by virtue of the immanence of the image.
These preliminary notions will now be applied to the following
exercises concerning the cervico-occipital joint. This region is investi
gated by three basic types of examinations:
- conventional radiography
- conventional tomography
- computerized tomography (CT)
Additional techniques may also be required, such as cisternobulbo
graphy, vertebral and carotid angiography, cervical phlebography, bone
scintigraphy, and even nuclear magnetic resonance (NMR). Only some
images concerning the one or the other of these techniques are shown
here since they are not utilized in daily routine radiology.
The analysis of an X-ray image requires a method. In practice, two
extreme conditions may occur:
1. There is a prominently pathological image which imposes itself right
away and may even monopolize attention to the point that minor
signs are relegated to the background and thus risk being overlooked
(Wackenheim 1984).
2. When there is no prominent image, the radiologist must force himself
to make a systematic reading of the image. I propose here a method
for the systematic reading· of frontal and lateral projections of the
cervico-occipital joint. This method is based on two principles: the
choice of the projection to be analyzed first and the choice of the
sequence of reading (Wackenheim 1985). According to these princi
ples, I isolated particular units (a part of the image) which are
significant (with a direct relationship between the signifiant and the
signifie) and pertinent (with a practical application covering a large
field of the pathology, such as rheumatology or traumatology).
2
In my opinion, radiology will increase its knowledge of the image
through the utilization of new methods of reading. I believe that these
methods have to develop along the lines of phenomenology and
structuralism. Indeed, the radiologist is nowadays in competition with
physicists on his technological wing and with specialized physicians on
the clinical wing.
As concerns the cervical region, I provide an example for the
practical utilization of the similitude and proximity rules. Indeed, the
cervico-occipital joint, which consists of the first two cervical vertebrae,
is seen on a lateral projection to be clearly different from the segment
formed by the three following vertebrae (C3-C4-C5). These latter
form a kind of block of three identical elements (the cervical triplet
schematized in Fig. 89). This triplet C3-C4-C5 is phenomenologically
autonomous. It forms the middle cervical segment, base of the cervico
occipital joint, and is almost affected by arthrosic changes, contra to the
underlying C5-C6 and C6-C7 segments.
Another example of structuralist reading is illustrated in Figs. 137,
139, and 140.
3
Part One
Iconography
5
