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Cervical Spine Trauma What Not To Miss

Cervical Spine Trauma What Not To Miss. Ellen G. Hoeffner, MD Neuroradiology Division Department of Radiology University of Michigan Health System. Objectives. Review which trauma patients need cervical spine imaging Review how to image a patient with suspected cervical spine trauma

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Cervical Spine Trauma What Not To Miss

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  1. Cervical Spine Trauma What Not To Miss Ellen G. Hoeffner, MDNeuroradiology DivisionDepartment of RadiologyUniversity of Michigan Health System

  2. Objectives • Review which trauma patients need cervical spine imaging • Review how to image a patient with suspected cervical spine trauma • X-rays/CT/MRI • Review imaging findings in lower cervical spine trauma

  3. Who To Image • Clinical rules have been developed to help guide physicians in the rational use of cervical spine imaging • NEXUS • Canadian Cervical Spine Rule

  4. Who To Image • National Emergency X-Radiography Use Study (NEXUS) (N Engl J Med 2000;343:94-9) • Identified clinical risk factors that had significant predictive value in determining a cervical spine fracture was absent • No imaging required in the absence of all of following criteria • 1. Midline posterior cervical spine tenderness • 2. Focal neurologic deficit • 3. Altered consciousness (GCS < 15) • 4. Intoxication • 5. Distracting, painful injury elsewhere

  5. Who To Image • Fully alert patient, GCS = 15 • Absence of high risk factors • Dangerous mechanism • Age > 65 • Parasthesias in extremities • Presence of any one of the low risk factors • Simple rear end MVA • Sitting position in ED • Ambulatory at any time • Delayed onset of neck pain • Absence of midline C spine tenderness • Can actively rotate neck 45 degrees to each side • Dangerous mechanism • Fall from > 1 meter/5 stairs • Axial load to head • MVA with high speed (>100 km/hr or 60 mph), rollover, ejection • Motorized recreational vehicle • Bicycle collision • • Canadian Cervical Spine Rule (JAMA 2001;286:1841-8) • ‒ Identified clinical criteria for which risk of cervical spine injury is low

  6. How To Image • Until late 1990s cervical spine x-rays were main modality • Helical and multidetector CT allowed faster scanning and improved reconstruction • Conventional x-rays compared to CT may miss up to… • 45% of cervical spine fractures • 55% of subluxations or dislocations (J Trauma 2003;55:222-7)

  7. How To Image • American College of Radiology (ACR) Appropriateness Criteria • CT with sagittal and coronal reformatted images listed as most appropriate for patients not meeting low risk criteria by NEXUS or CCR • CT should also be obtained in following • All patients with cervical spine injuries seen on x-rays • All patients with inadequate visualization on x-ray from occiput to T1

  8. How To Image • Indications for MRI • Neurologic deficit, either complete or incomplete • Guide treatment planning • Further assess subtle CT findings • Persistent neck pain and no fracture on CT • Clear C spine in obtunded/comatose patient • Determine if injury acute or chronic

  9. How To Image • Flexion extension x-rays • If MRI shows abnormal ligamentous signal but not complete disruption, flex/ext views may be useful to define extent and stability (J Emerg Med 2009;36:64-71) • Other uses of flex/ext films not indicated • Risk of secondary spinal cord injury • Provide inadequate visualization in up to 33% of patients • False negative rate of up to 57%

  10. Imaging of the Spine • 3 column theory • Anterior – ALL, anterior annulus, anterior vertebral body • Middle – posterior vertebral body, posterior annulus, PLL • Posterior – pedicles, facets, lamina, spinous processes, ligamentumflavum, intraspinous and supraspinous ligaments and facet joint capsule

  11. Imaging of the Spine • Two or more columns disrupted considered unstable • Other imaging features of instability • Displacement or translation > 2mm • Widening of interspinous space, facet joints, intervertebral disc or interpediculate distance • Disruption posterior vertebral body line • Widening of vertebral canal • Body height loss > 50% • Kyphosis >20%

  12. Lower (C3-C7) Cervical Spine Injuries • Often classified by mechanism of injury • Hyperflexion • Flexion rotation • Extension • Extension rotation • Burst

  13. Hyperflexion • Anterior subluxation (hyperflexion sprain) • Posterior ligament complex is disrupted • ALL remains intact • No bone injury, but facet joints may be subluxed • Subtle imaging findings • Anterior subluxation • Fanning of spinous processes • Localized widening of disc space posteriorly • Focal kyphoticangulation • 20% to 50% incidence of failed ligamentous healing leading to instability

  14. Hyperflexion • Wedge compression fracture • Flexion injury with loss of height anteriorly and buckling of the anterior cortex • Generally affects only anterior column and is stable • If posterior ligamentous complex is disrupted, then there is a potentially unstable, two-column injury

  15. C4 C4

  16. Hyperflexion • Bilateral interfacetal dislocation (BID) • Inferior facets from one vertebral body dislocate anterior to the superior facets of the subjacent vertebra • Subluxed or perched • Disruption of the major support ligaments of all 3 columns • Vertebral body is displaced anteriorly (usually 50% of the body width with complete dislocation) • Associated injuries • Compression fractures of the subjacent vertebra • Disc herniation at the level of the injury • High incidence of cord injury

  17. C7

  18. C7 C7

  19. Hyperflexion • Flexion teardrop fracture (Teardrop burst fracture) • Severe flexion and compression forces • Complete disruption of all soft tissues including ALL, intervertebral disc, and PLL • Coronal and sagittal comminuted vertebral body fractures • Triangular fragment found at anterior-inferior border • Retropulsed posterior cortex affects the ventral spinal canal • Acute anterior cord syndrome - quadriplegia and loss of the anterior column senses but preservation of the posterior column senses

  20. C3

  21. C3 C3

  22. Flexion Rotation • Unilateral interfacetal dislocation • Combination of flexion and rotation resulting in dislocation of one facet • Inferior articular facet displaced in front of the superior articular facet of the subjacent vertebra • Tearing of the posterior ligaments • Abrupt change in the amount of facet overlap on the lateral x-ray • Subluxation of the vertebral body may be minimal

  23. C5 C6 C5

  24. Extension • Forceful posterior displacement of the head or upper cervical spine • Generally affect lower cervical spine • Exception is extension teardrop at C2 body • More common in patients with ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis (DISH), or congenital or acquired spinal stenosis

  25. Extension • Hyperextension sprain and hyperextension dislocation • Injuries to the soft tissues from a hyperextension injury • Soft tissues involved may include longus colli and capitis muscles, ALL, intervertebral disc, and PLL • Hyperextension fracture dislocation • Disruption of the posterior vertebral body, articular pillars and posterior elements

  26. Extension • Radiographic signs can be subtle as these injuries can spontaneously reduce • Prevertebral soft tissue swelling • Intervertebral disc widened anteriorly • Disruption of ALL and anterior annulus fibrosis may result in avulsion of the anterior vertebral body endplate • Severe injuries may involve the middle and posterior columns

  27. C5 C5 C5 C5

  28. Extension Rotation • Articular pillar fracture • Impaction of articular mass during a hyperextension and rotational injury • Fracture usually extends into the ipsilateral transverse process, pedicle or lamina • Stable fracture

  29. C6 C6 C6 C7 C7 C6 C6

  30. C5 C5

  31. Axial compression • Burst fracture • Axial compression force results in nucleus pulposus imploding through the vertebral end plate • Combined sagittal and coronal splits in vertebral body • Retropulsion of bony fragments into the spinal canal • Less common in C spine than T and L spine

  32. C5 C4 C4 C5

  33. C4 C4

  34. Use of MRI • Persistent neck pain with negative CT

  35. Use of MRI • Determining age of fracture

  36. Use of Flexion Extension X-rays • Determining stability after MRI Neutral Flexion Extension

  37. Who/How To Image Meet Low Risk Criteria Meet Neither Criteria (ACR) No Imaging X-rays CT w/sag & cor reformats (Incomplete visualization or abnormal x-ray) CT w/sag & cor reformats

  38. Who/How To Image Neuro deficit, incomplete or complete Further assess subtle CT findings or guide tx planning Help determine if abnormality acute or chronic MRI (Lig abnormality without complete disruption) Persistent neck pain with CT neg for frx Help clear C spine in obtunded patient Flex/Ext X-rays

  39. Imaging Findings • Specific to level of injury and mechanism of injury

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