cervical spine imaging - lieberman's eradiology...
TRANSCRIPT
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Johannes Kratz, HMS IVGillian Lieberman, MD
Cervical Spine Imaging
Johannes Kratz, Harvard Medical School Year IV
Gillian Lieberman, MD
March 20, 2006
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Johannes Kratz, HMS IVGillian Lieberman, MD
Overview
• Background• Clinical Cases• Diagnostic Tests and a Decision-Tree Algorithm
• Examples of Cervical Spine Evaluations• Common C-spine fractures• Summary
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Johannes Kratz, HMS IVGillian Lieberman, MD
Cervical Spine Trauma
• 30,000 injuries to the spinal column every year in the US
• The majority of injuries are due to blunt trauma (motor vehicle accidents, falls, sports injuries, etc.)
• 2-3% of blunt trauma victims have cervical spine trauma
• 40-50% of spinal injuries produce a neurological deficit, often severe and sometimes fatal
• Costs of lifetime care and rehabilitation often exceed $1,000,000 per patient Souce: Bagley 2006
www.discoverchiropractichawaii.com
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Johannes Kratz, HMS IVGillian Lieberman, MD
BIDMC Cases
• Patient ND– 39 year old female s/p MVA. Awake, alert, no neck pain.
• Patient TN – 32 year old male s/p MVA. Awake, alert, complains of neck pain.
• Patient WD – 84 year old man s/p fall down 10-12 stairs at home. Awake, alert, “cannot move my arms”.
What kind of neck injuries might these patients have?
www.legeros.com
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Johannes Kratz, HMS IVGillian Lieberman, MD
Differential Diagnosis of Neck Pain s/p Trauma
• Cervical Spine Injuries– Cervical spine fracture– Spinal cord injury– Neck strain/Whiplash (ligaments, muscles, tendons)
• Epidural hematoma• Vertebral Artery Dissection• Atypical headache• Acute on Chronic neck pain (OA, radiculopathy, spinal stenosis, etc.)
How would you evaluate for the presence of c-spine injuries?
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Johannes Kratz, HMS IVGillian Lieberman, MD
Menu of Tests
What tests should be ordered and when?
Neck Trauma
No imaging is necessary or mandated
C-spine plain films C-spine CT
C-spine MRI
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Johannes Kratz, HMS IVGillian Lieberman, MD
Algorithm for C-spine imaging
Back to our patients…
Neurological Status
Patient is A&O x 3 Patient has ΔMS, focal neurological deficit or extremity paresthesia+ Neck Pain- Neck Pain
No imaging necessaryor mandated Plain films
Sources: Tins et al. 2004, NICE Guidelines 2003, Stiell et al. 2001.
CT (significant plain film finding OR negative plain film finding but
HIGH clinical suspicion)
MRI (ligamentousinjury suspected)
+/- +/-
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Johannes Kratz, HMS IVGillian Lieberman, MD
Patient ND39 year old female s/p MVA. Awake, alert,
no neck pain.
How about our second patient?
Patient is A&O x 3
- Neck Pain
No imaging necessaryor mandated
Patient has ΔMS, focal neurological deficit or
extremity paraesthesia+ Neck Pain
Plain films
CT (significant plain film finding OR negative plain film finding but
HIGH clinical suspicion)
MRI (ligamentousinjury suspected)
+/- +/-
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Johannes Kratz, HMS IVGillian Lieberman, MD
Patient TN32 year old male s/p MVA. Awake, alert,
complains of neck pain.
A 3 view c-spine plain film series is ordered
Patient is A&O x 3
- Neck Pain
No imaging necessaryor mandated (XXX study)
Patient has ΔMS, focal neurological deficit or
extremity paraesthesia+ Neck Pain
Plain films
CT (significant plain film finding OR negative plain film finding but
HIGH clinical suspicion)
MRI (ligamentousinjury suspected)
+/- +/-
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Johannes Kratz, HMS IVGillian Lieberman, MD
C-spine Anatomy: Atlas and Axis
How about the other cervical vertebrae?
Atlas (C1): superior view Axis (C2): posterosuperior
viewNetter 1997
Netter 1997
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________
_____________________
____
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Johannes Kratz, HMS IVGillian Lieberman, MD
C-spine Anatomy: 4th and 7th vetebrae
What holds the cervical vertebrae together?
Netter 1997
C4: superior view
Netter 1997
C3-C5: anterior view
________________________
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Johannes Kratz, HMS IVGillian Lieberman, MD
C-spine Anatomy: Cervical Spine Ligaments
How is this anatomy imaged?
Netter 1997 Atlantoaxial
joint: superior view
Netter 1997
Atlantooccipital
junction: midline sagittal
view
____________________________
______________________
___________
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Johannes Kratz, HMS IVGillian Lieberman, MD
3 View Plain Film C-spine Series
How do you interpret these films?lateral
A/P
Open Mouth
www.trauma.org
www.trauma.org
www.trauma.org
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Johannes Kratz, HMS IVGillian Lieberman, MD
Reading a Lateral C-spine Plain Film: 7 steps
What does TN’s lateral film look like?
• Quality Control• “See 7”. If can’t see C7, repeat
the film with the shoulders lowered.
• Evaluate 5 parallel lines• Prevertebral Line• Anterior Vertebral Line• Posterior Vertebral Line• Spinolaminal Line• Posterior Spinous Line
• Inspect the Dens• Dens-C1 body space <2.5mm (<5mm)
• Check the atlanto-occipital alignment• Check the bony landmarks• Check disc spaces• Check the soft tissue
www.trauma.org
normal
Sources: Brant and Helms 2004, Yao et al. 2000.
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Johannes Kratz, HMS IVGillian Lieberman, MD
TN’s Lateral C-spine Plain Film
What about the A/P film?normal TN
www.trauma.org PACS, BIDMC, courtesy of Dr. Lai
Non-displacedC1 fracture
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Johannes Kratz, HMS IVGillian Lieberman, MD
Reading an A/P C-spine Plain Film
What does TN’s A/P film look like?
• Quality Control• Evaluate 3 parallel lines
• Articular Pillar Line• Vertebral Body Line• Spinous Process Line
• Check the vertebral bodies• Check disc spaces
normal
Sources: Brant and Helms 2004, Yao et al. 2000.
www.trauma.org
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Johannes Kratz, HMS IVGillian Lieberman, MD
TN’s A/P C-spine Plain Film
What about the open mouth film?normal TN
www.trauma.org PACS, BIDMC, courtesy of Dr. Lai
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Johannes Kratz, HMS IVGillian Lieberman, MD
Reading an Open Mouth C-spine Plain Film
What does TN’s open mouth film look like?
• Quality Control• Examine the alignment
• Occipital condyles• Check the lateral dens
space• Check the lateral tips of
C1• Check the bony landmarks
normal
Sources: Brant and Helms 2004, Yao et al. 2000.
www.trauma.org
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Johannes Kratz, HMS IVGillian Lieberman, MD
TN’s Open Mouth C-spine Plain Film
What about our third patient?
normal TN
www.trauma.org PACS, BIDMC, courtesy of Dr. Lai
Lateral displacement of C1 massesaka “Jefferson Fracture”
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Johannes Kratz, HMS IVGillian Lieberman, MD
Patient WD84 year old man s/p fall down 10-12 stairs at
home. Awake, alert, “cannot move my arms”.
CT and MRI c-spine studies are ordered
Patient has ΔMS, focal neurological deficit or
extremity paraesthesia
Plain films
Patient is A&O x 3
- Neck Pain
No imaging necessaryor mandated (XXX study)
+ Neck Pain
CT (significant plain film finding OR negative plain film finding but
HIGH clinical suspicion)
MRI (ligamentousinjury suspected)
+/- +/-
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Johannes Kratz, HMS IVGillian Lieberman, MD
Patient WD: Sagittal CT
Right of midline Midline Left of midline
PACS, BIDMC, courtesy of Drs. Sun and Zeikus
“Locked” facets “Perched” facetsOsteophytes
AnterolisthesisCongenital block vertebrae
Bone fragment
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Johannes Kratz, HMS IVGillian Lieberman, MD
Patient WD: Axial CT
Is there ligamentous injury?
Normal facetsPACS, BIDMC, courtesy of Drs. Sun and Zeikus
“Naked facet sign”
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Johannes Kratz, HMS IVGillian Lieberman, MD
Patient WD: MRI
What about other common cervical spine fractures?
T2 weighted MRI STIR MRI
PACS, BIDMC, courtesy of Drs. Sun and Zeikus
Hematomas
Ligament injury
Hematomas
Ligament injury
“Locked/Perched Facets w/ ligament damage”
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Johannes Kratz, HMS IVGillian Lieberman, MD
Hangman’s Fracture
www.emedicine.com
Caused by a hyperextension injury
Displacement of C2 body
Fracture of posterior C2 elements
Source: Brant and Helms 2004
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Johannes Kratz, HMS IVGillian Lieberman, MD
Clay Shoveler’s Fracture
Source: Brant and Helms 2004
www.gentili.net
Classically caused by shoveling sticky clay over shoulder
Fracture of C6 spinous
process
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Johannes Kratz, HMS IVGillian Lieberman, MD
Flexion-Teardrop Fracture
www.emedhome.com
Source: Brant and Helms 2004
Caused by severe c-spine flexion
Associated with spinal cord injury
“Teardrop” frature
of an anterior
vertebral body
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Johannes Kratz, HMS IVGillian Lieberman, MD
Summary
• Significance of detecting cervical spine fractures
• Diagnostic Tests and a Decision-Tree Algorithm
• Clinical Examples of Cervical Spine Evaluations
• Common c-spine fractures: Jefferson, Locked/Perched Facets, Hangman’s, Clay Shoveler’s, Flexion-Teardrop
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Johannes Kratz, HMS IVGillian Lieberman, MD
Acknowledgements• Dr. Maryellen Sun, BIDMC Radiology• Dr. Eric Zeikus, BIDMC Radiology• Dr. Ken Lai, BIDMC Radiology• Dr. Jim Wu, BIDMC Radiology• Dr. Gillian Lieberman, BIDMC Radiology• Pamela Lepkowski, BIDMC Radiology• Larry Barbaras, Webmaster
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Johannes Kratz, HMS IVGillian Lieberman, MD
ReferencesBagley, L. Imaging of Spinal Trauma. Radiol Clin North Am 2006; 44:1-12.Banit, DM et al. Management of the Acute Cervical Spine: A Management
Algorithm. J Trauma 2000; 49:450-456.Brant, WE and Helms, CA. Fundamentals of Diagnostic Radiology. Lippincott
1999: 886-895.Brohi, K. Initial Assessment of Spinal Trauma.
http://www.trauma.org/spine/cspine-eval.html 2002; 7:4.Daffner, RH. Controversies in cervical spine imaging in trauma patients.
Emerg Radiol 2004; 11:2-8.Lingawi, SS. The Naked Facet Sign. Radiology 2001; 219:366-367.National Institute for Clinical Excellence. Head injury: triage, assessment,
investigation and early management of head injury in infants, children and adults—NICE guideline; 2003.
Netter, F. Atlas of Human Anatomy. Havas Medi Media 1997; 2:12-16.Radiographic assessment of the cervical spine in asymptomatic trauma
patients. Neurosurgery 2002; 50:S30-35.Radiographic assessment of the cervical spine in symptomatic trauma patients.
Neurosurgery 2002; 50:S36-43.Stiell IG, Wells GA, Vandernheen KL, et al. The Canadian C-spine rule for
radiography in alert and stable trauma patients. JAMA 2001; 286: 1841- 1848.
Tins, BJ and Cassar-Pullicino VN. Imaging of acute cervical spine injuries: review and outlook. Clin Radiol 2004; 59:865-880.
Yao, LL et al. Imaging Evaluation of the Cervical Spine. http://www.med- ed.virginia.edu/courses/rad/cspine/ 2000.