Cervical Spine InjuriesCervical Spine Injuries

Ric MohrRic Mohr

Following trauma or complaint of Following trauma or complaint of neck painneck pain• Obtain lateral, AP, and odontoid viewsObtain lateral, AP, and odontoid views

The lateral view is only adequate if T1 can The lateral view is only adequate if T1 can be visualizedbe visualized

If there is any doubt of fracture, If there is any doubt of fracture, obtain oblique views and consider CTobtain oblique views and consider CT

AlignmentAlignment

Key Things to IdentifyKey Things to Identify

Predental space – Predental space – should be 3mm or should be 3mm or lessless

Disc spaces should Disc spaces should be the equal and be the equal and symmetricsymmetric

Prevertebral soft Prevertebral soft tissuetissue• May be due to May be due to

hematoma from a hematoma from a fracturefracture

• Soft tissue swelling Soft tissue swelling may make fx dx may make fx dx difficultydifficulty

AP ViewAP View The height of the The height of the

cervical vertebral cervical vertebral bodies should be bodies should be approximately equal approximately equal

The height of each The height of each joint space should be joint space should be roughly equal at all roughly equal at all levels.levels.

Spinous process Spinous process should be in midline should be in midline and in good and in good alignment. alignment.

Odontoid ViewOdontoid View An adequate film should include An adequate film should include

the entire odontoid and the lateral the entire odontoid and the lateral borders of C1-C2. borders of C1-C2.

Occipital condyles should line up Occipital condyles should line up with the lateral masses and with the lateral masses and superior articular facet of C1.superior articular facet of C1.

The distance from the dens to the The distance from the dens to the lateral masses of C1 should be lateral masses of C1 should be equal bilaterally. equal bilaterally.

The tips of lateral mass of C1 The tips of lateral mass of C1 should line up with the lateral should line up with the lateral margins of the superior articular margins of the superior articular facet of C2. facet of C2.

The odontoid should have The odontoid should have uninterrupted cortical margins uninterrupted cortical margins blending with the body of C2. blending with the body of C2.

Hangman’s FractureHangman’s Fracture Fx through the pars reticularis of C2 secondary to Fx through the pars reticularis of C2 secondary to

hyperextensionhyperextension

Best seen on lateral viewBest seen on lateral view

Signs:Signs:• Prevertebral soft tissue swellingPrevertebral soft tissue swelling• Avulsion of anterior inferior corner of C2 associated Avulsion of anterior inferior corner of C2 associated

with rupture of the anterior longitudinal ligament. with rupture of the anterior longitudinal ligament. • Anterior dislocation of the C2 vertebral body. Anterior dislocation of the C2 vertebral body.

• Bilateral C2 pars interarticularis fractures.Bilateral C2 pars interarticularis fractures.

Jefferson FractureJefferson Fracture Compression fracture of the bony ring of C1, characterized by Compression fracture of the bony ring of C1, characterized by

lateral masses splitting and transverse ligament tear.lateral masses splitting and transverse ligament tear.

Best seen on odontoid viewBest seen on odontoid view

SignsSigns: : Displacement of the lateral masses of vertebrae C1 beyond Displacement of the lateral masses of vertebrae C1 beyond the margins of the body of vertebra C2. the margins of the body of vertebra C2.

CT is required to define the extent of fractureCT is required to define the extent of fracture

Odontoid FractureOdontoid Fracture Fracture of the odontoid (dens) of C2Fracture of the odontoid (dens) of C2

• 3 categories, I-III3 categories, I-III

Best seen on the lateral viewBest seen on the lateral view

Signs: Signs: • I – Fx through superior portion of densI – Fx through superior portion of dens• II – Fx through the base of the densII – Fx through the base of the dens• III – Fx that extends into the body of C2III – Fx that extends into the body of C2

Type IType I

Type IIType II

Type IIIType III

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

the vertebral body which results from a severe flexion injury.the vertebral body which results from a severe flexion injury.

Best seen on lateral viewBest seen on lateral view

Signs: Signs: • Prevertebral swelling associated with anterior longitudinal ligament Prevertebral swelling associated with anterior longitudinal ligament

tear.tear.

• Teardrop fragment from anterior vertebral body avulsion fracture.Teardrop fragment from anterior vertebral body avulsion fracture.

• Posterior vertebral body subluxation into the spinal canal.Posterior vertebral body subluxation into the spinal canal.

• Spinal cord compression from vertebral body displacement.Spinal cord compression from vertebral body displacement.

• Fracture of the spinous process. Fracture of the spinous process.

Bilateral Facet DislocationBilateral Facet Dislocation Complete anterior dislocation of the vertebral body Complete anterior dislocation of the vertebral body

resulting from extreme hyperflexion injury. It is associated resulting from extreme hyperflexion injury. It is associated with a very high risk of cord damage.with a very high risk of cord damage.

Best seen on lateral viewBest seen on lateral view

Signs: Signs: • Complete anterior dislocation of affected vertebral body Complete anterior dislocation of affected vertebral body

by half or more of the vertebral body AP diameter.by half or more of the vertebral body AP diameter.

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

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

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

resulting from rotatory injury of the cervical vertebrae. resulting from rotatory injury of the cervical vertebrae.

Best seen on lateral or oblique viewsBest seen on lateral or oblique views

Signs: Signs:

• Anterior dislocation of affected vertebral body by less than half of Anterior dislocation of affected vertebral body by less than half of the vertebral body AP diameter. the vertebral body AP diameter.

• Discordant rotation above and below involved level.Discordant rotation above and below involved level.

• Facet within intervertebral foramen on oblique view.Facet within intervertebral foramen on oblique view.

• Widening of the disk space.Widening of the disk space.

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

Anterior SubluxationAnterior Subluxation Disruption of the posterior ligamentous complex resulting from Disruption of the posterior ligamentous complex resulting from

hyperflexion. hyperflexion.

Signs:Signs:• Loss of normal cervical lordosis.Loss of normal cervical lordosis.• Anterior displacement of the vertebral body.Anterior displacement of the vertebral body.

• Fanning of the interspinous distance. Fanning of the interspinous distance.

Burst FractureBurst Fracture

Fracture of C3-C7 that results from Fracture of C3-C7 that results from axial compression. axial compression.

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

Clay Shoveler’s FractureClay Shoveler’s Fracture Fracture of a spinous process C6-T1Fracture of a spinous process C6-T1

Best seen on lateral viewBest seen on lateral view

Signs: Signs: • Spinous process fracture on lateral view.Spinous process fracture on lateral view.

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

Wedge FractureWedge Fracture Compression fracture resulting from flexion.Compression fracture resulting from flexion.

Signs: Signs: • Buckled anterior cortex. Buckled anterior cortex.

• Loss of height of anterior vertebral body. Loss of height of anterior vertebral body.

• Anterosuperior fracture of vertebral body.Anterosuperior fracture of vertebral body.

SummarySummary Key pointsKey points

• Lateral viewLateral view Top of T1 visibleTop of T1 visible Three smooth arcs maintainedThree smooth arcs maintained Vertebral bodies of uniform heightVertebral bodies of uniform height Odontoid intact and closely applied to C1Odontoid intact and closely applied to C1

• AP viewAP view Spinous processes straight and spaced equallySpinous processes straight and spaced equally Intervertebral spaces roughly equalIntervertebral spaces roughly equal

• Odontoid viewOdontoid view Odontoid intactOdontoid intact Equal spaces on either side of odontoidEqual spaces on either side of odontoid Lateral margins of C1 and C2 alignLateral margins of C1 and C2 align