practical approach to cervical spine traumabonepit.com/lectures/c-spine trauma a practical appraoch...
TRANSCRIPT
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Practical approach to Cervical Spine Trauma
• Dr. Donald E. Olofsson
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Acknowledgments
• A sincere and special thanks to Dr. Tudor Hughes
for his inspiration, outstanding teaching and for
his images.
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This was my best attempt.
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With Tudors help.
• Very professional.
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Overview
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Overview
• Readout
• Anatomy
• Technique
• Trauma
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Overview
• The scout view and reconstruction.
• Plain films: In and out of collar, flexion and
Extension views
• CT, series included and reconstructions
• Stable vs. unstable
• A few classifications
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Overview
•Reading Algorithm
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Reading Algorithm
• The scout view.
• Soft tissues including brain,tubes and lines.
• Bony alignment.
• Facet joint alignment.
• Look at common sites of fractures and the
second fracture.
• Other bones, and maximal STS.
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The scout view (The hidden view)
• Also known at the Naval Hospital as…The
staff view, the overview, the First view.
• Almost always included…Not always
pushed to PACS and not always viewed.
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The scout view
• Within voice recognition (AGFA Talk)
template you can add. [The scout view is
unremarkable.]
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There may be a free lateral view.
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A nice frontal view.
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You may find the cause of pain.
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Scout view with humeral fractures
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These were known fractures.
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Scout view unremarkable
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You can window and level the scout.
The Scout View
You will have to select the window/level from a different image.
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You can enlarge the scout.
The Scout View
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Discover unexpected findings.
The Scout View
Pneumothorax
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CXR several hours prior to CT
with Chest tube. The Scout View
• The lung was up prior to CT. The tube was either clamped for CT or not functioning.
• No AM CXR ordered.
• Ward team notified.
• Note: all of these scout views are from the same morning.
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Pulling the scout view on AGFA
• Including the statement [The scout view is
unremarkable.] in your template may help
remembering to do this.
• You are responsible for the image anyway
so the statement will not hurt you, and it
may serve as a reminder to pull and look at
the image.
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What the scout view can show.
• Fractures/Dislocations
• Tubes and lines
• Associated injuries
• Pneumothorax
• Foreign bodies
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Reconstructing the CT images
• Bring up the CT.
• Reconstruct the thin axial images.
• Bring up the sagittal images.
• Rotate to create a true axial.
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Reconstructing the CT images
• Level the axial from the coronal view.
• Double click the axial image to enlarge.
• Scroll the axial images C1 to about C3.
• Rotate off the sagittal for C4.
• Scroll
• Rotate off the sagittal for C5-T1.
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Anatomy
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Anatomy
• The anatomy of C3-
C6 is basically the
same.
• The anatomy of C1,C2
and C7 are special.
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Normal C-SPINE
The Atlas & Axis
C1 the Atlas:Anterior and posterior arch &
Lat Masses, Small transverse
process (contains transverse
foramen)
C2 the Axis:Body, lat masses, lamina,
spinous process and
Ondontoid process (dens).
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Craniocervical Ligaments
Netter
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C3-C6
• Body
• Lamina
• Spinous Process
• Transverse process
• Pedicle & Transverse
process
• Articulating facets
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Anatomy
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C-Spine AP
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Lateral view: Anatomy
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Oblique View: Anatomy
Greenspan
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Oblique View: Anatomy
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Technique
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Technique - Routine
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30M MVA Thought to be paraplegic
Lateral view: Technique
C7
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Lateral view: Technique
30M MVA Thought to be paraplegic
C7
C7
C7
C7-T1 Fracture Dislocation
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Technique - Flexion / Extension
Open C1 posterior arch
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Technique - Flexion / Extension
30F post trauma acute films
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Technique - Flexion / Extension
30F post trauma 8d later
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Peg # hard to see 37M
Flexion and Extension
Extension
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Peg # hard to see 37M
Flexion and Extension
Flexion
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Technique - CT• Excellent visualization of fractures
• Must be optimized
– Thin slices 1 - 1.25 - 2mm
– Bone and soft tissue algorithm / window
– Orthogonal planes
• Thin recons
– Use workstation
– 3D for alignment
Bifacet Dislocation
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Technique - MRI
• Poor visualization of fractures
• Good for soft tissue injury
• Good for spinal cord injury assessment
• Good for spinal cord injury prognosis
• Good for root avulsion
Romanoff Fracture
C7
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C5
C-5 facet fracture not well seen on plain
films
Technique - CT
5
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C5
C-5 facet fracture not well seen on plain
films Technique - MR
5 Sag T2FS
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CT: Type l Odontoid Fracture
Technique - CT
2.5mm Standard algorithm 2.5mm Bone 1.25mm Bone
3
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Optimizing CT
• Half axial acquisition.
• Reducing dose.
• Altering pitch.
• Slice thickness.
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Fractures
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Life lines
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Reading Algorithm
Life Lines
Evaluate C1-C2 Area
Adults: <3mm
Child: <5mm
1. Anterior vertebral body
line
2. Posterior vertebral
body line
3. Spinolamina line
4. Posterior spinous
process line
Greenspan
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Cx-Spine Stability
UnstableAtlantooccipital disassociation
UnstableOdontoid fracturesComplex
StableBurst fracture
UnstableJefferson fractureCompression
UnstableHyperextension dislocation fracture
StableExtension teardrop fracture
StablePillar fracture
StableLaminar fracture
UnstableHangman’s fracture
StablePosterior arch C1 fractureExtension
StableClay-shoveler’s fracture
UnstableFlexion teardrop fracture
StableWedge compression fracture
UnstableBilateral facet dislocation
StableUnilateral facet dislocation
StableAnterior SubluxationFlexion
Stable vs. Unstable
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Compression Fractures
• Stable
• Burst fracture
• Unstable
• Jefferson fracture
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Flexion: stable vs. unstable
• Stable
• Unilateral facet
dislocation
• Wedge Compression
• Clay Shovel's
• Unstable
• Bilateral facet
dislocation
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Extension: stable vs. unstable
• Posterior arch C1
• Laminar
• Pilar
• Extension tear drop
• Hangman’s
• Hyperextension
dislocation fracture
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Pseudo (physiologic) Subluxation
• In children
• Ligament laxity
• Check Posterior Spinal (cervical) Line
• More than 2-3mm offset (SLL anterior to PSL at C2) must be considered traumatic.
C2
Caffey and Swischuk
C1
C3
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Atlas
•Atlanto Occipital Dislocation
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Atlanto Occipital Dislocation
• 40% missed dx at presentation
• STS +/- Retropharyngeal air
• Avulsion fractures occipital condyle or lower tip of clivus
• Classification:
Normal I II III
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Atlanto Occipital Dislocation
Causes:
• Traumatic
• Nontraumatic• RA
• Congenital Skeletal Abnormalities
• Down’s
• Infection
• CPPD
• Prognosis not good – (but 20% may have no deficit!)
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Atlantooccipital subluxation
• BDI (Basion Dental Interval) – Vertical distance of basion above dens <12 mm
• BAI (Basion Axial Interval)– Anterior distance of basion from PSL 4 – 12 mm
• Powers ratio: – Basion to C1 Posterior lamina line / Opisthion to posterior cortex
of the anterior C1 tubercle <1
• X method of Lee
• Clival line
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Occipito atlas separation
Power’s ratio
Powers B, et al. Neurosurgery. 1979 Jan;4(1):12-7.
Traumatic anterior Atlanto-occipital dislocation.
BC should be less than AO
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The X-line
X
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Occipito atlas separation
X Line
Lee C, et al AJNR Am J Neuroradiol. 1994 May;15(5):990.
Evaluation of traumatic atlantooccipital dislocations.
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Occipito atlas separation
Clival Line - Normal
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Occipito atlas separation
Basion Axial Interval
Harris JH Jr
AJR Am J Roentgenol. 1994 Apr;162(4):887-92.
Radiologic diagnosis of traumatic occipitovertebral dissociation:
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Atlanto-occipital Dislocation.
Atlanto axial and cranial
atlas separation 32MPowers
B
C
A
O
Powers B, et al. Neurosurgery. 1979 Jan;4(1):12-7.
Traumatic anterior Atlanto-occipital dislocation.
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Atlanto-occipital Dislocation.
X methodLee C, et al AJNR Am J Neuroradiol. 1994 May;15(5):990.
Evaluation of traumatic atlantooccipital dislocations.
Atlanto axial and cranial
atlas separation 32M
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Atlanto-occipital Dislocation.
Atlanto axial and cranial atlas separation 32MClival line
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Atlanto-occipital Dislocation.
Atlanto axial and cranial atlas separation 32MBasion Dens intervalHarris JH Jr AJR Am J Roentgenol. 1994 Apr;162(4):887-92.
Radiologic diagnosis of traumatic occipitovertebral dissociation:
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Atlanto-occipital Dislocation.
13 y.o girl s/p MVA unconscious
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28M MCA
Atlanto-occipital Dislocation.
3
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Atlantooccipital subluxation
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Atlas
Fractures
– Jefferson
– Isolated posterior arch
Subluxation
– Atlanto axial
– Rotary
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Atlas – C1
•Jefferson
Fracture
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Jefferson Fracture
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Jefferson Fracture
(Burst Fracture of C1)
• Compression to vertex
• Diving injury
• Rx. Halo for 3m
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Jefferson Fracture
(Burst Fracture of C1)
• Radiographic findings
– AP open mouth is key
– C1 lateral masses laterally displaced
– >2mm bilaterally always abnormal
– 1-2mm unilaterally may be head tilt
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Vertical Compression – Unstable
1. Unilateral or Bilat FX’s of both ant and post arches of C1
2. Displacement of lateral masses.
3. CT required for defining full extent of fracture and detecting fragments in spinal cord/canal
4. Treatment: Halo placement for 3 months
Jefferson Fracture (Burst Fracture of C1)
Greenspan
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Vertical Compression – Unstable
1. Unilateral or Bilat FX’s of both ant and post arches of C1
2. Displacement of lateral masses.
3. CT required for defining full extent of fracture and detecting fragments in spinal cord/canal
4. Treatment: Halo placement for 3 months
Jefferson Fracture (Burst Fracture of C1)
Normal
Direction of forces
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Jefferson Fracture
• Axial loading
• Often 4 part Fx, or single both side
fractures
• Splaying of lateral masses
• Disruption of transverse ligament
• Best seen on AP odontoid and axial CT
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Jefferson Fracture
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Atlanto Axial Distance
• Females < 2mm
• Males < 3mm
• Children < 4mm
Hinck 1966
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Axis
•Odontoid
Fracture
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Dens Fractures
TYPE 1 - Avulsion fx of the tip.
Considered Stable
TYPE II - Fx at Base of Dens.
Most Common
Poor blood supply
Unstable
TYPE III - Fx into body of axis
Best Prognosis
Unstable
Anderson and D’AlonzoGreenspan
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Type l Odontoid Fracture
22M MVA6
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Type l Odontoid Fracture
22M MVA4
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Axis
•Type 2
•Odontoid Fracture
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Type ll Odontoid Fracture
73M
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Type ll Odontoid Fracture
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S/P MVA
Type ll Odontoid Fracture
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Mac band
? Type ll Odontoid Fracture
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Axis
•Type 3
•Odontoid Fracture
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Displaced type 3 odontoid fx
18M
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Low Type lll Odontoid fracture
26M
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57M
Type lll Odontoid Fracture
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Type lll Odontoid Fracture
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Axis
•Hangman
Fracture
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Hangman Fracture - Unstable
• Traumatic Spondylolisthesis of the Axis
• Bilateral C2 pars (common) or Pedicle (less common)
• Hyperextension and traction injury of C2
– MVA (chin to dashboard)
– Hanging
• The odontoid and its attachments are intact.
• Nerve damage is uncommon owing to the width of the canal at this level.
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Hangman Fracture - Unstable
• Traumatic Spondylolisthesis of the Axis
• Bilateral C2 pars (common) or Pedicle (less common)
• Hyperextension and traction injury of C2– MVA (chin to dashboard)
– Hanging
• The odontoid and its attachments are intact.
• Nerve damage is uncommon owing to the width of the canal at this level.
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Effendi classification
Grade 1: extension injury, displacement < 2mm. Rx flexion.
Grade 2: extension injury, displacement >2mm and
angulation. Rx flexion.
Grade 3: flexion injury, C2-3 facet joint subluxation/
dislocation. Rx extension.
Hangman Fracture - Unstable
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Effendi classification
Type I: bilateral pars fractures, normal C2/C3 disc space
and minimal / no displacement of C2 body. LE1
Type II: displacement of anterior fragment, abnormal
C2/C3 disc LE2b
Type III: anterior displacement of the anterior fragment,
body of C2 in flexed position, bilateral facet dislocation
LE2a/LE3
Hangman Fracture - Unstable
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Levin and Edward’s
Type 1: Neural arch fracture, < 3mm displacement, no angulation
Type 2: A; + angulation
Type 2: B; + >3mm displacement
Type 3: + bilateral facet dislocation C2-3
Hangman Fracture - Unstable
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• Hangman Effendi 1
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Hangman Fx
20M
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32 Y.O. Drunk, fell off cliff
Hangman Fracture – Effendi l
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• Hangman effendi 2
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Hangman Fracture – Effendi ll –
LE2a
Posterior arch C1 Fx
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Hangman Fracture – Effendi lll – LE3
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C3-7• Fractures
– Tear drop
• Flexion
• Extension
• Posterior
– Burst
– Posterior arch
– Clayshoveller’s Fracture
• Dislocations• Unifacet
• Bifacet
• Fracture Dislocations• Unilateral
• Bilateral
– Floating lateral mass
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C3-7
•Wedge
•Compression
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Wedge Compression Fracture
• Usually stable
• Loss of height anterior vertebral body
• Buckled anterior cortex
• Anterosuperior fracture of body
• Differentiate from Burst– Lack of vertical fracture component
– Posterior cortex intact
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C3-7
•Flexion
Teardrop
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Flexion Teardrop
• Flexion Fracture Dislocation
• Unstable
• Most severe Cervical spine injury
• Anterior cord syndrome– Quadriplegia
– Loss of anterior column senses
– Retention of posterior column senses
• Associated with Tx or Lx spine Fx in 10%
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Flexion Teardrop
• Teardrop fracture – anteroinferior
• All ligaments disrupted
• Posterior subluxation of vertebral body
• Bilateral subluxated or dislocated facets
• Spinal canal compromise
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C5-C6 Flexion Distraction Teardrop
35M MVA
C5
C6
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C4 Flexion Teardrop
Tear drop 2 level dislocation
C4
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C5 and C7 tear drop fractures
21M1+32+3+5
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C5 and C7 tear drop fractures
21M
C5
C7
2+5
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1. Significant Prevert ST Swelling
2. Comminuted Fx of body of C6
with Anterior displacement of a
teardrop fracture fragment.
19y.o s/p mva
C6 Flexion Teardrop
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C3-7
•Extension
Teardrop
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Extension Teardrop Fracture
• Avulsion fracture of
anteroinferior corner of
C2>C3>C4
• Radiographic findings
– Teardrop pulled off by
ALL
– Vertical height of
fragment >= width
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C2 Extension Teardrop
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C3 Extension Teardrop
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C5 Extension Teardrop
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C3-7
•ALL
•Rupture
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Anterior Longitudinal Ligament Rupture
C6-7
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C3-7
•Posterior
Teardrop
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C6 Posterior Teardrop
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C6
C6 Posterior Teardrop
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C6
C6 Posterior Teardrop
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C3-7
•Burst Fracture
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Burst Fractures• Same mechanism as Jefferson Fx but located at
C3-C7.
• Injury to spinal cord (due to displacement of posterior fragments) is common.
• Requires CT to evaluate.
• Stable
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C5 Burst Fracture
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48 y.o s/p mva with quadriplegia
1. Prevert ST Swelling
2. Comminuted FX of C5
w/slight retrolisthesis
of C5/6
3. Extension of Fx into
the posterior elements
Burst FX of C5 Flexion teardrop mechanism
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CT, Burst FX of C5
48 y.o s/p mva with quadriplegia
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C3-7
•Facet
Dislocation
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Facet Dislocation - Subluxations• Anterior subluxation
(hyperflexion strain)– The Posterior Ligament complex
is disrupted. (30-50% can show delayed instability)
• Unilateral facet dislocation (stable)– Results from simultaneous flexion
and rotation
• Bilateral Facet Dislocation (unstable)– Results from extreme flexion of
head and neck without axial compression
Greenspan
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Facet Dislocation - Subluxations• Anterior subluxation
(hyperflexion strain)– The Posterior Ligament complex
is disrupted. (30-50% can show delayed instability)
• Unilateral facet dislocation (stable)– Results from simultaneous flexion
and rotation
• Bilateral Facet Dislocation (unstable)– Results from extreme flexion of
head and neck without axial compression
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Facet Dislocation - Subluxations• Anterior subluxation (hyperflexion strain)
– The Posterior Ligament complex is disrupted. (30-50% can show delayed instability)
• Unilateral facet dislocation (stable)– Results from simultaneous flexion and rotation
• Bilateral Facet Dislocation (unstable)– Results from extreme flexion of head and neck without axial compression
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C3-7
•Unilateral
•Facet Dislocation
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Unilateral Facet Dislocation
• Simultaneous flexion and rotation
• Best seen on lateral and oblique views
• Vertebral body subluxation < ½ of AP width
• Disrupted “shingles on a roof” on oblique view
• Facet within foramen on oblique view
• Disrupted posterior ligaments
• Disrupted SP line on AP
• Butterfly appears
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33 y.o. s/p MVA
1. Prevert ST Normal
2. Normal Alignment
3. Abrupt change in
rotation at level of C4-
C5.
4. Facets superimposed at
C5-6-7.
Rotational Subluxation
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33 y.o. s/p MVA
Rotational Subluxation
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C2-3 Unilateral jumped facet
40F
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C6-7 Unilateral jumped facet
C6
7Butterfly
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C5-6 Unilateral jumped facet
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C5-6 Unilateral jumped facet
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C5-6 Unilateral locked facet
33 y.o s/p MVA
Lost Hamburger sign
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22 Y.O. S /P MVA
1. Prevert ST Normal
2. Gd I anterolisthesis of
C6 on C7
3. Facets of C7 and T1
superimposed while
facets of C6 are abruptly
obliqued on C7
C6-7 Unilateral locked facet
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22 Y.O. S /P MVA
Unilateral facet lock, C6 on C7
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C3-7
•Bifacet
Dislocation
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Bifacet Dislocation
• Extreme flexion without compression
• Unstable
• Vertebral body anterolisthesis > ½ AP body
• Batwing or bowtie appearance of adjacent facets
• Wide SP on AP view
• Disrupted ALL, disc and posterior ligaments
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C7-T1 Bifacet dislocations
46F
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C7-T1 Bifacet dislocations
46F
Sag T1 Sag T2 Sag STIR
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C3-7
•Unifacet Fracture Dislocation
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Unifacet Fracture Dislocation
• More common than pure dislocation
• Signs as before + fracture
• Fracture of facet often not seen on
radiographs
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C6
C6
61M MVA
C5-6 Uni Facet Fracture
Subluxation
C5
C5C6
C5
1+4+6+3+1
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C6
C5
61M MVA
C5-6 Uni Facet Fracture
Subluxation
C6
3+6+3+1
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C6C6
C5
61M MVA
C5-6 Uni Facet Fracture
Subluxation
6+3+1
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C4-5 Fracture Dislocation
22M
C4
C4
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C4-5 Fracture Dislocation
C4
22M
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C4-5 Fracture Dislocation
22M
C4
C5
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Sag T1 Sag T2
C4-5 Fracture Dislocation
22M1
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C6-7 Fx subluxation
25M MVA1+11+18
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C5-6 Uni Fx dis with post op
unstable C4-5
17M
C5
C6
C6
C5
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C5-6 Uni Fx dis with post op
unstable C4-5
17M
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C3-7
•Bifacet Fracture Dislocation
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Bifacet Fracture Dislocation
• Higher energy than bifacet dislocation
• MVA
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C3-7
•Facet Fracture
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Hyperextension fracture
dislocation
• Severe circular hyperextension force
– Impact on forehead
• Anterior vertebral displacement
• Unstable
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Hyperextension fracture
dislocation
• Radiographic findings
– Mild anterior subluxation
– Comminuted articular mass fracture
– Contralateral facet subluxation
– Disrupted ALL, PLL
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Hyperextension fracture
dislocation
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Clay Shovlers
• The shoveler: Special
power shoveling.
• Weakness: Spinous
process fractures.
•http://www.imdb.com/title/tt0132347/
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The Mystery Men
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C3-7
•Clay Shoveler’s Fracture
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Clay Shoveler’s Fracture
• Oblique avulsion fx of spinous process
• C7 > C6 > T1 levels
• Due to powerful hyperflexion
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Clay Shoveler’s Fracture
• Best seen on lateral view
• Double spinous process on AP
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28 y.o construction worker
Clay Shoveler’s Fx
1. Oblique avulsion fx of
the spinous process
(C7 > C6 > T1)
2. Mechanism:
Hyperflexion
3. Stable
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Old C6 clay shoveler’s
41F2
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C3-7
•Flexion
Subluxation
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Anterior Subluxation
• Hyperflexion sprain
• Posterior ligament complex disrupted
• 20-50% show delayed instability
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Anterior Subluxation
• Radiographic findings
– Localized kyphotic angle
– Fanning• Widened interspinous/interlaminar distance
– Posterior widening of disc space
– Subluxation of facet joints
– Anterior subluxation
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Facet Dislocation - Subluxations• Anterior subluxation
(hyperflexion strain)– The Posterior Ligament complex
is disrupted. (30-50% can show delayed instability)
• Unilateral facet dislocation (stable)– Results from simultaneous flexion
and rotation
• Bilateral Facet Dislocation (unstable)– Results from extreme flexion of
head and neck without axial compression
Greenspan
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C3-4 Flexion subluxation injury
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Unstable Posterior Ligamentous Injury at C5-C6
27 y.o. female 3 mo s/p trauma with more recent “neck crackings” by chiropractor.
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Unstable Posterior Ligamentous Injury at C5-C6
27 y.o. female 3 mo s/p trauma with more recent “neck crackings” by chiropractor.
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Stability
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Cx-Spine - Stability
• Stability is a function of ligamentous injury
• Can be inferred from radiographs for certain
fracture patterns
• Not 100% accurate
– Eg. Flexion subluxation
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Cx-Spine - Stability
Greenspan
An unstable injury, is one which can progress and cause cord injury.
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Flexion Anterior Subluxation Stable
Unilateral facet dislocation Stable
Bilateral facet dislocation Unstable
Wedge compression fracture Stable
Flexion teardrop fracture Unstable
Clay-shoveler’s fracture Stable
Extension Posterior arch C1 fracture Stable
Hangman’s fracture Unstable
Laminar fracture Stable
Pillar fracture Stable
Extension teardrop fracture Stable
Hyperextension dislocation fracture Unstable
Compression Jefferson fracture Unstable
Burst fracture Stable
Complex Odontoid fractures Unstable
Atlantooccipital disassociation Unstable
Stability
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Cervical Spine - Stability
• MRI
– Shows
• Edema of soft tissues
• Paravertebral hematoma
• Ligamentous disruption
– Still does not indicate instability
– Negative study does not indicate stability
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Cx-Spine - Stability
• Flexion Extension views
– Patient should be erect
– Should wait 2w for spasm to resolve
– Must see to T1
– Must move > 30 degrees
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Cx-Spine signs of instability on Flex/Ex.
• Subluxation greater than 3.5mm
• Angular deformity of more than 11 deg.
• Compression fx more than 25% loss of height
• Narrowing of the disk space.
• Widening of the interspinous distance 1.5X
• Facet joint widening
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PEARLS• One view is no view.
• 20% of spinal fractures are multiple
• 5% of spinal fractures are at discontinuous levels
• Most spinal fractures occur in upper (C1-C2) or
lower (C5-C7) regions
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PEARLS (Cont)•Spinal cord injury occurs
–At time of trauma 84%
–As a late complication 15%
•Any signs/symptoms of cord injury require MRI.
•Get CT in patients with unexplained prevertebral soft tissue swelling.
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Online credits:
• www.crayola.com
• www.rad.washington.edu
• www.ispub.com
• www.radiographicceu.com
• http://www.imdb.com/title/tt0132347/
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If your head comes away from
your neck, it’s over!
The Highlander http://www.imdb.com