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8/14/2019 SPINEFX

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Cervical SpineSpine Trauma

Edward C. Fritsch, D.C.Edward C. Fritsch, D.C.

Assistant Professor of RadiologyAssistant Professor of Radiology

Texas Chiropractic CollegeTexas Chiropractic College

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CERVICAL TRAUMA SERIESCERVICAL TRAUMA SERIES

s Neutral Lateral Neutral Lateral

x Erect vs. cross-tableErect vs. cross-table

s

APOM & APL5APOM & APL5s Bilateral ObliquesBilateral Obliques

s Flexion & Extension LateralFlexion & Extension Lateral

s Extra viewsExtra viewsx Pillar viewsPillar views

x Lateral bending viewsLateral bending views

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Cervical Spine

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Neutral Lateral Cervical Spine Neutral Lateral Cervical Spine

s Prevertebral soft tissues:Prevertebral soft tissues:

x In adults:In adults:3 No more than 5mm at C3 & C4 No more than 5mm at C3 & C4

3 Less than 22 mm at C6Less than 22 mm at C6

x In children:In children:3

Two thirds of the width of C2 body at C3 and C4.Two thirds of the width of C2 body at C3 and C4.3 Not more than 14 mm at C6. Not more than 14 mm at C6.

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Pre-vertebral Soft Tissues

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Pre-vertebral Soft Tissues

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Pre-vertebral

Soft Tissues

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Neutral Lateral Cervical Spine

s Cervical lordosis:Cervical lordosis:

x Reversal - indicates myospasmReversal - indicates myospasm

x Hypolordosis - may represent muscle spasm;Hypolordosis - may represent muscle spasm;

normally absent in 20% of patientsnormally absent in 20% of patients

x It is absent in 70% of normal patients if theIt is absent in 70% of normal patients if the

chin is depressed only 1 inch.chin is depressed only 1 inch.

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Reversed Cervical Lordosis

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s Four continuous curves describe the normalFour continuous curves describe the normal

position of the bony elements: position of the bony elements:

x Anterior vertebral body lineAnterior vertebral body line

x Posterior vertebral body linePosterior vertebral body line

x Spinal laminar lineSpinal laminar line

x Posterior spinous process linePosterior spinous process line

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Neutral Lateral Cervical SpineNeutral Lateral Cervical Spine

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s Abnormal fanning of the spinousAbnormal fanning of the spinous

s Abrupt change in overlap of Abrupt change in overlap of

facets indicates an abnormalfacets indicates an abnormal

rotation.rotation.

s Dens is normally tiltedDens is normally tilted

posteriorly on the body of C2. posteriorly on the body of C2.

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s AtlantodentalAtlantodental

interspace (ADI)interspace (ADI)

x

Adults <3 mm andAdults <3 mm anddoes not change withdoes not change with

flexionflexion

x Children = 5mm andChildren = 5mm and

may change by 1 to 2may change by 1 to 2mm with flexion.mm with flexion.

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AP Cervical Spine

s May provide a valuable clue to spinousMay provide a valuable clue to spinous

process avulsion. process avulsion.

s The spinous processes should form aThe spinous processes should form a

continuous line .continuous line .

s Evaluate articular pillars.Evaluate articular pillars.

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Oblique Views

s Used to evaluate posterior elements for Used to evaluate posterior elements for

fracture and confirm normal overlap of fracture and confirm normal overlap of

facets.facets.x Perched facetsPerched facets

x Articular pillar fracturesArticular pillar fractures

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LPO / RAOLPO / RAO RPO / LAORPO / LAO

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AP Open-mouth View

s Used to evaluate the odontoid process for Used to evaluate the odontoid process for

fracture.fracture.

s Used also to evaluate the integrity of theUsed also to evaluate the integrity of the

ring of the atlas (Jefferson’s Fracture).ring of the atlas (Jefferson’s Fracture).

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Other films:

s Lateral flexion & extension views:Lateral flexion & extension views:

x Help evaluate the extent of the injury and theHelp evaluate the extent of the injury and the

degree of stabilitydegree of stabilityx The patient is allowed to flex and extend alone,The patient is allowed to flex and extend alone,

withoutwithout force.force.

x

A physician must supervise the filming, and theA physician must supervise the filming, and the patient should be awake, cooperative, and patient should be awake, cooperative, and

neurologically intactneurologically intact..

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Other films:

s Pillar views:Pillar views:

x Used to profile the facets & articular pillars.Used to profile the facets & articular pillars.

x Watch for facet compression or fracture,Watch for facet compression or fracture,

especially in hypertension injury.especially in hypertension injury.

x Consider computed tomographyConsider computed tomography

s Swimmers view:Swimmers view:x Used to clear the cervicothroracic junction.Used to clear the cervicothroracic junction.

x Bilateral oblique films may do the same.Bilateral oblique films may do the same.

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Anomalies & Variants.

s Fusion or lack-of-segmentation anomaliesFusion or lack-of-segmentation anomalies

s Occipitalization of the atlas.Occipitalization of the atlas.

s Absence or lack of fusion of ossificationAbsence or lack of fusion of ossification

centers is especially confusing at C1 andcenters is especially confusing at C1 and

C2.C2.

x Os terminaleOs terminale

x Os odontoideumOs odontoideum

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Os Odontodium

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Os Odontodium

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Fractures & Dislocations of

the Cervical Spine

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Fracture Incidence of 400

Vertebral Trauma Patients

Vertebral Arch 50%

Vertebral Body 30%

Intervertebral Disc 20%

Posterior ligaments 10%

Dens 14%

Locked Facets 12%

Anterior ligaments 2%

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Fracture Incidence of 400

Vertebral Trauma PatientsC1 6%

C2 27%

C3 10%

C4 10%

C5 18%

C6 27%

C7 18%

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Radiographic Signs of Instability:

s Spinous process fanning.Spinous process fanning.

s Widening of intervertebral disk space.Widening of intervertebral disk space.

s Horizontal displacement of one body onHorizontal displacement of one body on

another more than 3.5 mm.another more than 3.5 mm.

s Angulation greater than 11 degrees.Angulation greater than 11 degrees.

s Disruption of facets.Disruption of facets.

s Severe injury, such as multiple fractures atSevere injury, such as multiple fractures at

one segment.one segment.

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Classification System

s HyperflexionHyperflexion

s CompressionCompression

s HyperextensionHyperextension

s Unknown mechanismUnknown mechanism

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Classification System

s HyperflexionHyperflexion

x StableStable

3 Anterior subluxationAnterior subluxation3 Anterior vertebral compressionAnterior vertebral compression

3 ““Clay-shoveller” avulsion FractureClay-shoveller” avulsion Fracture

x

UnstableUnstable3 Anterior subluxationAnterior subluxation

3 Bilateral facetal dislocationBilateral facetal dislocation

3 Flexion tear-drop fractureFlexion tear-drop fracture

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Hyperflexion Injuries:

s Hyperflexion sprain-anterior subluxation:Hyperflexion sprain-anterior subluxation:

x Posterior ligamentous complex disruptedPosterior ligamentous complex disrupted

x Localized increased height of intervertebralLocalized increased height of intervertebraldisk spacedisk space

x Fanning of spinous processes and a localFanning of spinous processes and a local

kyphotic angulation.kyphotic angulation.x May allow facet subluxation or locking.May allow facet subluxation or locking.

x There is delayed instability in 20%!There is delayed instability in 20%!

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s Anterior wedge:Anterior wedge:

x Relatively minor injury,Relatively minor injury,

not usually associated withnot usually associated with posterior retropulsion of posterior retropulsion of

the body.the body.

x StableStable

x Neurologically intact Neurologically intact


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C-6C-6

Hyperflexion Injuries:Hyperflexion Injuries:

Wedge Fracture at C-7Wedge Fracture at C-7

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C-6C-6

C-6C-6

Hyperflexion Injuries:Hyperflexion Injuries:

Wedge Fracture at C-7Wedge Fracture at C-7

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CT Wedge Fracture at C-7

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Hyperflexion Injuries

s Bilateral locked facet:Bilateral locked facet:

x Due to flexion with enough distraction for Due to flexion with enough distraction for

facets to become disarticulated.facets to become disarticulated.x The vertical body is displaced approximatelyThe vertical body is displaced approximately

50% of the body length on the lateral film.50% of the body length on the lateral film.

x

Both lateral and oblique films show theBoth lateral and oblique films show the"jumped," locked facets."jumped," locked facets.

x High incidence of cord damage.High incidence of cord damage.

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Bilateral FacetBilateral Facet

DislocationDislocation

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s Clay-shoveler's fracture:Clay-shoveler's fracture:

x Avulsion of the spinous processes (usually C6Avulsion of the spinous processes (usually C6

or C7) due to flexionor C7) due to flexionx "Double" process seen on AP."Double" process seen on AP.

x May need swimmers view or oblique films toMay need swimmers view or oblique films to

confirmconfirm

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Clay-shoveler's fracture

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Clay-shoveler's Fracture

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Clay-shoveler's Fracture

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s Teardrop burst fracture:Teardrop burst fracture:

x Most severe flexion fractureMost severe flexion fracture

x Comminuted vertebral body fracture withComminuted vertebral body fracture withtriangular fragment from the anterorinferior triangular fragment from the anterorinferior

border of the body. border of the body.

x

The posterior body is displaced into the canalThe posterior body is displaced into the canalwith high probability of neural damage.with high probability of neural damage.

x Anterior cord syndromeAnterior cord syndrome

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Teardrop Burst FractureTeardrop Burst Fracture

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Classification Systems

Flexion-RotationFlexion-Rotationx StableStable

3 Unilateral facet dislocationUnilateral facet dislocation

s

Extension-RotationExtension-Rotationx StableStable

3 Fracture of articular mass (pillar fractureFracture of articular mass (pillar fracture

s

Vertical CompressionVertical Compressionx Stable or UnstableStable or Unstable

3 Jefferson fractureJefferson fracture

3 C3 - C7 burst fractureC3 - C7 burst fracture

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Flexion-Rotation Injuries

s Unilateral locked facet:Unilateral locked facet:

x Due to flexion, distraction and rotation.Due to flexion, distraction and rotation.

x An abrupt change in amount of facet overlap onAn abrupt change in amount of facet overlap onlateral film and oblique films.lateral film and oblique films.

x Disruption of the posterior vertebral body line.Disruption of the posterior vertebral body line.

x

Most common locations are C4-5 and C5-6.Most common locations are C4-5 and C5-6.x 35% are associated with fracture (usually35% are associated with fracture (usually

facet).facet).

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Compression InjuriesCompression Injuries

s Fractures of the Atlas (C1)Fractures of the Atlas (C1) x Jefferson's fracture Jefferson's fracture

x

Compression mechanismCompression mechanismx Burst fracture both arches.Burst fracture both arches.

x Stable, and usually neurologically intactStable, and usually neurologically intact

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Jefferson's Fracture

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APOM AP Tomogram


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Complex or Unknown Mechanism

s

UnstableUnstablex Atlanto-occipital dislocationAtlanto-occipital dislocation

x Ondontoid process fractureOndontoid process fracture

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Fractures of the Axis (C2)

s Odontoid (dens) fracture:Odontoid (dens) fracture:

s Classification:Classification:

x

Type 1: +Type 1: +3 Stable, RareStable, Rare

3 DDX from os terminaleDDX from os terminale

x Type 2:Type 2:3

Unstable, most commonUnstable, most common3 DDX os odontoidiumDDX os odontoidium

x Type 3:Type 3:3 Stable, uncommonStable, uncommon

D F t

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Dens Fractures

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Dens Fractures

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Dens Fractures

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Classification Systems HyperextensionHyperextension

x StableStable3 Fracture of the posterior arch of atlasFracture of the posterior arch of atlas

3 Avulsion fracture of anterior arch of atlasAvulsion fracture of anterior arch of atlas

3 Laminar fractureLaminar fracture

x UnstableUnstable3

Extension tear-droop fracture (C2 - C7)Extension tear-droop fracture (C2 - C7)3 Hangman’s fractureHangman’s fracture

3 Hyperextension dislocation +/- fractureHyperextension dislocation +/- fracture

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Fractures of the Axis (C2)

s Hangman's fracture:Hangman's fracture:x Traumatic spondylolisthesisTraumatic spondylolisthesis

x Hyperextension injury resulting inHyperextension injury resulting in

bilateral neural arch fractures. bilateral neural arch fractures.

x Initially neurologically intact but veryInitially neurologically intact but very

unstableunstable

x The odontoid and its attachments areThe odontoid and its attachments are

intact; nerve damage is uncommonintact; nerve damage is uncommon

owing to the width of the canal at thisowing to the width of the canal at this

level.level.

Hangman's FractureHangman's Fracture

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Hangman s FractureHangman s Fracture

H ' F tH ' F t

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H ' F tH ' F t

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Extension Injuries:

s Subtle findingsSubtle findings

s Prevertebral soft tissue swelling.Prevertebral soft tissue swelling.

s Posterior body displacement.Posterior body displacement.

s Widened anterior disc space.Widened anterior disc space.

s Vacuum phenomenon:Vacuum phenomenon:

x Highly suggestive of anterior soft tissue injury.Highly suggestive of anterior soft tissue injury.

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Extension Injuries:

s Avulsion fracture from the anteroinferior Avulsion fracture from the anteroinferior

margin, especially of C2 or C3.margin, especially of C2 or C3.

s Facet (pillar) compression fracture:Facet (pillar) compression fracture:x Bilateral or unilateral.Bilateral or unilateral.

x Pillar views and/or CT.Pillar views and/or CT.

x May result in nerve root compression.May result in nerve root compression.

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Pediatric Cervical Spine Fractures

s Parameters for evaluation are different.Parameters for evaluation are different.

s Sites of involvement tend to be different:Sites of involvement tend to be different:

x Teenagers have similar distribution to adults.Teenagers have similar distribution to adults.

x Children under 12 years old involve mostlyChildren under 12 years old involve mostly

occiput-C1 & C1-C2.occiput-C1 & C1-C2.

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