What  to  do  if  the  spine  x-­‐ray  shows  a  …    

Dr  Paul  Licina                                                      Dr  Greg  Cowderoy  Spine  surgeon                                                                  Radiologist  

MVA with Flexion Injury Report : Alignment is satisfactory. Small fracture at the anterior corner C3. Disc degeneration and narrowing C3 –C6.

Flexion Teardrop Fracture   Posterior ligament disruption and anterior compression fracture of the

vertebral body which results from a severe flexion injury.

  Best seen on lateral view

  Signs: Prevertebral swelling associated with anterior longitudinal ligament tear.

  Teardrop fragment from anterior vertebral body avulsion fracture.   Posterior vertebral body subluxation into the spinal canal.

  Spinal cord compression from vertebral body displacement.

  Fracture of the spinous process.

45 yr M

  Axial injury onto head off mountain bike

  C/O neck pain at coffee after the ride

  Otherwise well

Bilateral Facet Dislocation

  Anterior dislocation of the vertebral body resulting from extreme hyperflexion injury. It is associated with a very high risk of cord damage.

  Best seen on lateral view

  Signs:   Anterior dislocation of affected vertebral body by half or more of

the vertebral body AP diameter.

  Disruption of the posterior ligament complex and the anterior longitudinal ligament.

  "Bow tie" or " bat wing" appearance of the locked facets.

Unilateral Facet Dislocation   Facet joint dislocation and rupture of the apophyseal joint

ligaments resulting from rotatory injury of the cervical vertebrae.

  Best seen on lateral or oblique views

  Signs:   Anterior dislocation of affected vertebral body by less than half

of the vertebral body AP diameter.

  Discordant rotation above and below involved level.

  Facet within intervertebral foramen on oblique view.

  Widening of the disk space.

  "Bow tie" or "bat wing" appearance of the overriding locked facets.

30 yr M

  Persisting pain 3 weeks after MVA.

  Neck stiffness

  No Neurology

  X-ray – Mild acute angle kyphosis at C5/6 with widening of the interspinous distance. No fracture is seen.

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Hyperflexion Injury

  Disruption of the posterior ligamentous complex resulting from hyperflexion.

  Signs:

  Loss of normal cervical lordosis.

  Anterior displacement of the vertebral body.   Fanning of the interspinous distance.

C/O Neck Pain following preseason rugby camp.

Clay Shoveler’s Fracture

  Fracture of a spinous process C6-T1

  Best seen on lateral view

  Signs:

Spinous process fracture on lateral view.

  Ghost sign on AP view (i.e. double spinous process of C6 or C7 resulting from displaced fractured spinous process).

40 yr male

•  Lumbar back pain following mountain bike accident

•  No radiculopathy

•  Tender mid lumbar spine

Report: Mildly displaced fractures of the left transverse processes of L2 and L3. No other fracture identified.

Crush Fractures And yet another fall in the making!

•  Mechanism

•  Low Energy- Osteoporotic

Elderly

•  High Energy- All ages.

Need to exclude more significant injury

– Burst fracture

-- Chance fracture

Crush Fractures

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Burst Fracture

  Fracture that results from axial compression.

  Burst fracture is a type of compression fracture which results in disruption of the posterior vertebral body cortex with retropulsion into the spinal canal. When involves the thoracolumbar level, it tends to occur between T9 and L5 levels . Burst fractures may be stable or unstable.

  CT and MR is required for all patients to evaluate extent of injury.

Flexion Injury on holidays

  Severe thoracolumbar back pain and tenderness

  No radiculopathy

  Haematuria

Chance Fracture

PERCUTANEOUS VERTEBROPLASTY INDICATIONS

 Painful crush fracture  Osteoporosis  Few weeks

 Malignant crush fracture  Biopsy + vertebroplasty

 Haemangioma  Galibert 1987

PERCUTANEOUS VERTEBROPLASTY PATIENT SELECTION is the key to success

  Back pain   Sudden onset   May radiate anteriorly   NOT sciatica   Mechanical   Restricted activity   Poor sleep

  Local tenderness

PREPROCEDURE IMAGING

 Purposes of pre-procedure imaging:  Confirm presence of crush fracture  Confirm that crush fracture is acute/ununited  Diagnose other acute levels  Integrity of spinal canal  Accurately localise level

MRI PRE-VERTEBROPLASTY

  Sagittal plane

  T1 for anatomy

  T2 fat saturation or STIR   Marrow black

  Oedema white

MRI

2

3

2

3

NEEDLE PLACEMENT LUMBAR

CEMENT INJECTION

PERCUTANEOUS VERTEBROPLASTY LITERATURE

Amar Neurosurg 2001;49:1105

 97 pat., 258 levels

 ‘better life’ 74%   Narcotic/analgesic use   Mobility

  Better sleep

Evans Radiology 2003;226:366   488 pat, 245 follow-up   Pain scale 8.9 → 3.4   Impaired ambulation:   72% pre → 28% post

N Engl J Med. 2009 Aug 6;361(6):557-68.

  A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures.

  No benefit of vertebroplasty compared with a placebo procedure

PERCUTANEOUS VERTEBROPLASTY LOCAL RESULTS

  Sept 2001 – June 2004

  131 procedures

  112 patients   F 78, M 34   Ages 58-94, average 76

  186 levels

  ‘Complete’ response 73.3%

  Moderate response 17.6%

  No response 9.2%

Scoliosis Classification: 

  Idiopathic: 80%   Infantile <3; Juvenile 4-10; Adolescent: 10-18

  Or:   Early onset <5; Late onset >5

  Congenital: Osteogenic: hemivertebra, fused vertebra

  Neurogenic: tethered cord, syringomyelia, Chiari

  Developmental: Achondroplasia

  NF   OI

  Neuromuscular:   Cerebral palsy

Tumour:   Osteoid osteoma

  BPNST