Illustration: Posterior cervical column
Neuroradiology
Case TypeClinical Case
Authors
Vicente Halpern Araya, Olalla Vázquez Muiños, Victor Pérez-Riverola, Khaled El-Hamshari Rebollo, Mario Prenafeta Moreno
Patient38 years, male
A 38-year-old male presents with a 6-month history of neck pain radiating to both shoulders, without associated neuropathic symptoms. He reports excessive physical labour prior to the onset of symptoms, including carrying heavy bags on his back. The physical examination was unremarkable. There was an improvement in symptoms after a few weeks of medical treatment.
Cervical spine CT and MRI (T1, T1 FAT-SAT with contrast, T2, and STIR sequences) showed high signal intensity on T2 and STIR sequences, with enhancement in the posterior third of the C7 spinous process and surrounding soft tissues involving the interspinous and supraspinous ligaments at this level. A small erosion was identified on the right side of the tip of the C7 spinous process (Figure 2), along with a small laminar fluid collection above the tip.
Neck pain is one of the four leading causes of disability [1], with interspinous bursitis being an often underestimated cause. These bursae consist of narrow slits composed of synovial cells on a bed of fibro-adipose tissue, located near the undersurface of the upper spinous process and extending dorsally from the ligamentum flavum [2,3]. The cervical location of the bursae is associated with the close contact of the spinous processes, leading to laxity and damage of the interspinous ligaments due to fibrillation and/or rupture, producing inflammatory changes and bursae formation [4]. They are most frequently located at the C6–C7 level but can be present in all cervical interspaces except C1–C2 [4].
There are established associations between cervical interspinous bursitis and polymyalgia rheumatica (PMR), rheumatoid arthritis, juvenile idiopathic arthritis, and crystalopathies [2,4,6].
It manifests as aching and stiffness in the cervical region, with associated shoulder pain in the majority of patients [4]. Clinically, it can mimic other conditions, such as meningitis [7].
Imaging findings include inflammatory changes surrounding the interspinous ligaments, showing oedema, marked local soft tissue enhancement in contrast sequences [9] and well-circumscribed fluid collections adjacent to the tip and/or superior border of the spinous process, indicative of bursitis [10].
Differential diagnoses include: avulsion fracture of the spinous process, where CT improves the sensitivity to evaluate bone erosion or avulsion/fracture; spondylodiscitis, characterised by the clinical context and poorly-defined inflammatory changes of paravertebral soft tissue, disc, and vertebral end plates affecting more than one level; neoplasms like multiple myeloma and metastasis, which are the main tumours affecting the spine; and meningocele, a protrusion of the spinal membranes through a bone defect that simulates filled bursae.
In cases of bursitis caused by systemic inflammatory conditions, it is important to treat the underlying condition [10]. Patients with polymyalgia rheumatica have shown a rapid response to oral glucocorticoids within the first 7 days [11]. For refractory cases, bursitis can be treated surgically, usually by endoscopic or arthroscopic procedures [10].
Take Home Message
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[6] Blecher R, Yilmaz E, Tawfik T, Abdul-Jabbar A, O'Lynnger T, Moisi M, Hart R, Hanscom D, Oskouian RJ, Tubbs RS, Chapman J (2017) Cervico-thoracic Interspinous Bursitis Associated with Bilateral Upper-extremity Numbness: A Case Report. Cureus 9(11):e1897. doi: 10.7759/cureus.1897. (PMID: 29399425)
[7] Garcia-Gonzalez E, Baldi C, Guidelli GM, Selvi E (2013) Crowned dens syndrome and cervical interspinous bursitis mimicking acute meningitis. J Clin Rheumatol 19(6):357-8. doi: 10.1097/RHU.0b013e3182a2a0d5. (PMID: 23965487)
[8] Leão RV, Calich ALG, Calich I, Rodrigues MB, Helito PVP, Amaral DT, Pereira RFB, Correa MFP (2022) Magnetic resonance imaging findings in patients with polymyalgia rheumatica. Radiol Bras 55(6):346-52. doi: 10.1590/0100-3984.2021.0151. (PMID: 36514685)
[9] Viroslav A (2022) Cervical Interspinous Bursitis. In: MRI Web Clinics - December 2022. Radsource [Internet]. https://radsource.us/cervical-interspinous-bursitis/
[10] Williams CH, Jamal Z, Sternard BT. Bursitis (Update: 20 Feb 2023). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. (PMID: 30020712)
[11] Gonzalez-Gay MA (2008) The clinical implication of cervical interspinous bursitis in the diagnosis of polymyalgia rheumatica. Ann Rheum Dis 67(6):733-4. doi: 10.1136/ard.2008.087999. (PMID: 18474656)
URL: | https://eurorad.org/case/18627 |
DOI: | 10.35100/eurorad/case.18627 |
ISSN: | 1563-4086 |
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