C-SPINE TRAUMA

JULIANA TSURUTARadiology Fellow

12/05/2016

TOPICS

• Clinical assessment• Imaging• Injuries• Management• Quiz

NEXUS CRITERIA

• Sensitivity(S) 99.6%• No age cut-off however– >65 y.o - S:66-84%

• Safely reduce imaging 12-36% - cost

NEXUS CRITERIA

• Midline cervical spine tenderness• Focal neurological deficit• Intoxication• Painful distracting injury• Altered mental status– GCS < 15– Disorientation in time, place, person or event– Inability to recall 3 objects at 5 minutes– Delayed or inappropriate response to stimulus

NEXUS CRITERIA

• If ALL criteria are negative:– No need for imaging

• If positive:– CT– MRI

CANADIAN C-SPINE RULE (CCR)

• For all alert (GCS = 15) and stable trauma patients where cervical spine injury is a concern

Harborview criteria:- Presence of significant head injury- Presence of focal neurological deficit(s)- Presence of pelvic or multiple extremity

fracture- Combined impact of accident >50km/h- Death at the scene of the MVA- Accident involved a fall from a height ≥ 3m

IMAGING

• Radiography vs CT– Low x high risk of CSI– Accuracy– Ionising radiation– Cost

IMAGING

• Literature:– Combined S of plain films 53% vs CT 98%– Five-views plain films failed to identify 52% of

cervical spine fractures identified by CT imaging– Choose CT– 3 view plain film: If CT not available• AP• Lateral• Odointoid

TC PLAIN FILMS

Se 97.4 44

Sp 100 100

PPV 100 100

NPV 99.7 93.2

IMAGING

• Obtunded/unexaminable patients:– Flexion and extension fluoroscopy: inadequate– MRI: despite negative CT, if clinical suspicious

persists• Improved the probab of identifying significant CSI by

8%• Controversial

IMAGING

• Signs of instability:– More than one vertebral column involvement– Increased or reduced intervertebral disc space

height– Increased interspinous distance– Facet joint widening– Vertebral compression greater than 25%

IMAGING

• Normal

NORMAL PREDENTAL SPACE:- < 3 mm in adults- <5 mm in children

C1 C2

HARRIS’ RING:- The ring should be complete

C1

C2

The spinolaminar line should intersect the

opisthion

Basion-Dental Interval:- Distance between the tip of the clivus (basion) should be <12mm (XR) and <8.5mm (CT) from the tip of the dens

Posterior axial line:-a line drawn along the posterior VBs should be <12mm from the basion

Lateral aspects of the lateral masses should have <1-2mm of malalignment

The atlanto-dental spaces should be symmetric

LATERAL MASS ALIGNMENT

Smooth contours of the 4 following lines:- Anterior VB line- Posterior VB line- Articular pillars- Spinolaminar line

Important: focal contour abnormality!!

C2: <7mmC3-C4: <5mmC6: <22mm (adults) / <14mm (children >15yo)

IMAGING

• Mechanism– Hyperflexion: most common• Flexion teardrop fracture• Clay-shoveler fracture• Facet dislocation

– Bilateral (no rotation)– Unilateral (with rotation)

• Anterior subluxation

FLEXION TEARDROP FRACTURE• Flexion and compression: C5/6• Anterior cervical cord syndrome and quadriplegia• Radiographic features:

– Sagittal fracture through the vertebral body (VB)– Fracture of AI VB– Loss of anterior height of VB– Cervical kyphosis– Posterior cervical displacement above the level of injury– Widening of interspinous processes– Intervertebral disc space narrowing– Disruption of the spinolamellar line– VB rotation with an AP diameter that appears smaller than on other levels– Anterior dislocation of facet joints

FLEXION TEARDROP FRACTURE

• DDX: extension teardrop fracture• MRI for further spinal cord injury• CTA for blunt cerebrovascular injury• Unstable

CLAY-SHOVELER FRACTURE

• Fracture of spinous process of lower cervical spine (C7)

• Usually a stress fracture• Acute onset: MVA, muscle contraction and

direct blows to the spine• Stable

FACET DISLOCATION

• Anterior displacement of one vertebral body on another

• Forced flexion and distraction• Bilateral: unstable (no rotation)– Associated with significant spinal cord injury– Bowtie sign

• Unilateral: stable (with rotation)– Associated with monoradiculopathy that improves

with traction

ANTERIOR SUBLUXATION

• Hyperflexion sprain• Ligamentous injury– If not diagnosed: delayed instability

• Usually stable • Radiographic features:– Kyphotic deformity– Widened spinous processes– Widened of the posterior aspect of the involved disc space– May have associated wedge fracture

IMAGING

• Mechanism– Hyperextension:• Hangman fracture• Extension teardrop fracture

HANGMAN FRACTURE

• Traumatic spondylolisthesis of axis• Never seen in hanging• High speed MVA• Bilateral lamina and pedicle fracture at C2• Usually associated with anterolisthesis of C2 on C3• If extension to transverse foramina: ?vertebral

artery injury• Stable/unstable (if facet dislocation)

EXTENSION TEARDROP FRACTURE

• Avulsion of anteroinferior corner of the VB• Unstable • Older: C2• Radiographic features:– Avulsion fracture of the attachment of the anterior

longitudinal ligament– Fragment is triangular in shape (teardrop)– Vertical height of fragment is equal or greater than

width

C3

C2C2

EXTENSION TEADROP FRACTURE

• Additional features are common: CT is indicated in all cases

IMAGING

• Mechanism:– Axial compression:• Jefferson fracture• Burst (compression) fracture

JEFFERSON FRACTURE

• Burst fracture of C1• Diving head first into shallow water• Not normally associated with neurological deficit– Retropulsed fragment

• Associations:– Other C-spine injuries (50%)– C2 fracture (33%)– Head injury (children 25-50%)– BCVI – vertebral artery injury – Extra-cranial nerve injury

JEFFERSON FRACTURE

• Radiographic features:– Asymmetry in odontoid view:• Displacement of lateral mass(es) away from dens

– Usually involves anterior and posterior arch• Unstable

BURST FRACTURE

• High energy axial loading• Disruption of posterior VB cortex with

retropulsion into the spinal canal• Common: thoracolumbar transition zone • Fall from significant height• Unstable

BURST FRACTURE

• Radiographic features:– Loss of vertebral height– Disruption of posterior VB cortex– Retropulsed fragments may occur– Interpedicular widening– Vertical fracture through posterior elements

• DDx:– Wedge fracture– Chance fracture– Osteoporotic compression fracture

IMAGING

• Mechanism– Complex injuries:• Odontoid fracture• Atlanto-occipital dissociation

ODONTOID FRACTURE

• Peg or dens fracture• Flexion or extension with or without compression• Common • Classification:– Anderson and D’Alonzo

• Most commonly used• Level of fracture line

– Roy-Camille • Better correlate with prognosis• Plane of fracture and displacement

ODONTOID FRACTURE

Rare/stable

Common/unstable/poor healing

Usually stable/better prognosis than II

ODONTOID FRACTURE

• DDx:– Os odontoideum– Persistent ossiculum terminale– Mach effect

MACH EFFECT

OS ODONTOIDEUM

PERSISTENT OSSICULUM TERMINALE

ATLANTO-OCCIPITAL DISSOCIATION

• Atlanto-occipital dislocations and subluxations• Unstable:– Tectorial membrane and alar ligaments

• Uncommon• Fatal• More common in children: larger head• Up to 50% are overlook initially

ATLANTO-OCCIPITAL DISSOCIATIONS

• Radiographic features:– Disruption of normal alignment – Basion-dens interval (BDI)> 10 mm in adults– Basion-axial interval (BAI) > 12 mm in adults– Atlantodental interval • > 3 mm in adult males• > 2.5 mm in adult females

BDI ADI BAI

QUIZ

CASE 1

• 31y.o male• MVA

• What is the type of fracture?• Any other associated injury?• Unstable or stable?

• Hangman fracture• Extension to the foramina• CTA: left vertebral dissection• Unstable

CASE 2

• 35 y.o• Thrown off a horse• Landed on head• Hyperextension injury• Was paralysed for 15 min. Normal now.

• Type of fracture?• Unstable or stable?

• Type III odontoid peg fracture with up to 5 mm displacement of the superior fragment posteriorly with some narrowing of the spinal canal at this level.

• There is posterior subluxation of C1 lateral masses on C2.

• Usually stable.

• After 3 months

CASE 3

• 22 y.o male• Forced hyperflexion injury following tackle

during AFL• Felt click• Midline tenderness at C2-C4 with right

paravertebral spasm• No focal neurology

• Type of injury?• Stable or unstable?• Other associated injuries?

• Unilateral facet-joint fracture-dislocation at the right C3/4 level (perched)

• With comminuted fracture associated through the inferior tip of the right inferior articular facet of C3 with 5 mm superior displacement

• Anterolisthesis of C3 (4mm)• Ligamentous/spinal cord injury – MRI• Vertebral artery injury – CTA

CASE 4

• 85 y.o female• Nursing home• Unwitnessed fall• Midline tenderness• Recent C2-C6 fractures March 2014• Left humerus and clavicular fracture

• Type of fracture?• Complication?• Stable or unstable?

• Type II odontoid peg fracture• Minimal posterior displacement• Unstable• Non union is highly frequent

CASE 5

• 28 y.o. male• MVA

• Type of fracture?• Stable or unstable?

• Extension teardrop fracture• Anteroinferior avulsion of C2 vertebral body

CASE 6

• 26 y.o. male• MVA

• Mechanism of injury?• Radiographic features?

• Hyperextension injury• Radiographic features:– Widened anterior disc space– Anterior avulsion fracture– Narrowing/impaction of posterior elements

• Anterior wedging of the C6 and C7 vertebral bodies with widening of the C6/7 disc space

• Fracture lines extends through both C6 laminae• Small osseous fragments are noted at the right C6/7 neural

exit foramina• Superior end plate fracture of C7 which extends to traverse

the right vertebral artery foramen• The left vertebral artery foramen is also traversed by a

fracture line• Ligamentous injury – MRI• Vertebral artery injury – CTA

CASE 7

• 32 y.o. male• Previous C1 fracture• Assess fracture healing

• Type of fracture?• Do you see any sign of healing?

• Jefferson fracture (burst fracture of C1)• Oblique fractures of C2 and C7 again noted• C1 fracture demonstrates interval bony

remodeling and bony bridging at the posterior arch. The left anterior arch component remains unfused with callus and bony remodelling

References• AFP vol 41 no 4 April 2012 pages 196-201• ANZCOR Guideline 9.1.6 Jan 2016• Trauma Victoria – Spinal Trauma Guideline• NEXUS Criteria• AANS – guidelines for the management of acute cervical spine and spinal cord

injuries• Radiology: Volume 263: Number 3—June 2012 • RadioGraphics Volume 8,Number 4 }uly,1988• http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/mu

sculoskeletal-trauma/bone-and-joint-trauma/cervical-spine-injury#pathway

• Radiopaedia.org• Radiologyassistant.nl• Neurosurgery 72:54-72, 2013• https://www.youtube.com/watch?v=skLoiQgzi5s

THANK YOU!